Upon the implementation of ICD10 in October, 2015, CMS updated many LCDs, which no longer listed allowed diagnoses but provided coverage indications, limitations and medical necessity policy for Special and IHC Stains. This was discussed in APS’ White Paper acknowledging that Cigna Adopted LCD L35986 (updated 6/27/16).
As a recap, the LCD applicable, after implementation of ICD10 for these stains first indicates that it is not meant to designate specific stains to be used in differential diagnosis of tissue or neoplasms because this information is readily available in text books and various scientific publications. The policy instead identifies medically necessary criteria for the use of these stains based on claims reviews and overutilization or incorrect billing for the services which includes:
Since our last newsletter, LCD L35986 has been superseded and republished on the CMS website. There were no changes to the entire LCD, but only to the section pertaining to prostate cases. The changes are meant to further outline where ordering IHC stains on prostate cases are medically reasonable and necessary. The LCD states that “prostate cases that may require reasonable and necessary IHC staining include, but are not limited to, the following” (changes in this section are highlighted in red below):
Additionally, CMS added verbiage to this section of the LCD to highlight when IHC should not be used. CMS states, “Prostate cases when IHC workup is not reasonable and necessary include the following”:
There were no other changes to this LCD in its current version. The full LCD can be found at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35986&ContrId=228&ver=7&ContrVer=2&CntrctrSelected=228*2&Cntrctr=228&name=CGS+Administrators%2c+LLC+(15102%2c+MAC+-+Part+B)&DocType=Active%7cFuture%7cAllProposed&LCntrctr=228*2&bc=AgACAAQAAAAAAA%3d%3d&
APS’ coding team continues to work hard to ensure our client’s compliance and revenue are not at risk through routine coding and documentation audits. As the first year of ICD10 comes to an end, we will continue to monitor this and other LCDs implemented by all MACs and provide necessary feedback to ensure your billing integrity.