The Society for Vascular Surgery (SVS) Coding Committee is best known for its work developing CPT (Current Procedural Terminology) codes, recommending physician work relative value units (RVUs) as well as working to address Medicare payment issues. However, the committee also represents the SVS and its members with coverage issues.
Understanding third-party payor coverage policies is essential to ensuring reimbursement for your services. Coverage polices are confusing and highly variable between third-party payors and even between regions for the same payor. This article provides information about this issue for Medicare fee-for-service (i.e., traditional Medicare), Medicare Advantage and commercial payors—as well as what the committee can do to help.
Medicare rules and regulations are the basis for most Medicare coverage policies, and commercial payors often follow Medicare policies. The program is a federal one, but claims are processed
by commercial health insurers, known as Medicare Administrative Contractors (MAC), who cover two distinct geographic jurisdictions. Although MACs can individually determine what is and what is not covered, they must follow certain Medicare guidelines.
The Medicare Coverage Database provides beneficiaries and clinicians access to coverage policies. These are in the form of National and Local Coverage Determinations (NCD and LCD). The NCDs and LCDs may provide a list of inclusive diagnosis codes for coverage or rely on a description of what constitutes “medical necessity.” These coverage decisions, which can change annually, serve as the basis for reimbursement for services within a MAC’s jurisdiction.
Medicare Advantage (Part C) must cover the same Medicare Part A and Part B services as are covered by traditional Medicare fee-for-service.
However, Medicare Advantage, administered by commercial payors, often offers additional services and also often has additional rules and policies. Medicare Advantage plans can require “in-house” referrals, restrict access to specialists and require prior authorization (PA) for many services, which is not required for most traditional Medicare services.
Differences between traditional Medicare and Medicare Advantage in coverage policies, deductibles and annual out-of-pocket caps can impact the care beneficiaries receive.
Commercial payors also have coverage policies that may include a time-consuming “precertification process” for some services, requiring input of multiple medical parameters into an automated medical review algorithm to determine if a patient meets clinical indications.
Commercial payors also may create their own version of an LCD by providing a list of services and acceptable diagnosis codes as well as inclusion and exclusion criteria for coverage.
Sadly, even if all the steps are followed and a preauthorization is obtained, reimbursement is not assured, as the claim may be denied for any number of reasons. Doctors and surgeons do have several avenues of recourse. However, if a pattern of denied coverage or reimbursement doesn’t pass the sniff test, the SVS Coding Committee is a valuable resource.
Once the member provides background information, including copies of policies, denials, appeals and more, the committee will process the issue through a coverage decision tree. For example, is the denial appropriate? Was proper documentation submitted with the claim? Has an appeal been processed? How widespread is the issue? It can then respond accordingly.
The Coding Committee also addresses coverage issues through a collection of external information and payor engagement. These may include LCDs, the Carrier Advisory Committees (CAC), the Center for Medicare and Medicaid Services (CMS) national regulations, CMS NCDs and private payor policies. The committee will send letters and/or have meetings with payors to advocate for appropriate coverage for vascular surgery services.
The committee also works with other societies on coverage issues when indicated. For example, SVS recently worked with the Society for Vascular Ultrasound (SVU) on an Aetna physiologic studies policy and with the Society for Interventional Radiology, the Society for Cardiovascular Angiography and Interventions and the American College of Cardiology on a United Health lower-extremity coverage issue.
Once a medically inappropriate policy takes hold in a state or region, it is often then adopted by other carriers in locations around the country.
To mitigate development of undesirable vascular surgery coverage policies, the SVS Coding Committee pre-emptively develops model policies as a means to efficiently communicate what SVS believes to be correct coverage for vascular surgery services, based on current evidence and professional society guidelines.
These model policies do not serve as clinical guidelines but instead are a way to be ready in order to address coverage issues as they arise. The SVS Coding Committee is currently working with SVU on a model vascular studies policy.
A key to success is to get out in front of coverage issues early. A primary SVS Coding Committee goal is to reduce the administrative burden and increase the timeliness of payments so the membership can then turn its focus onto providing excellent comprehensive vascular care.
The next time you encounter a coverage issue, please contact the SVS Coding Committee, housed within the Advocacy Council, by emailing [email protected].