Medicare Complaint

TrailBlazer’s decision to limit certain debridements (11043 and 11044) is wrong on a number of levels.  First, the decision to limit these debridements to 5 is based on flawed statistics.  The sampling base was all physicians who provided any debridement service and the data points fell in a very non-Gaussian distribution.  Yet, this “data” was interrogated using standard deviations based on a bell-shaped curve.  This is the “science” behind where the number 5 originated for TrailBlazer.

Second, patients not classified elderly or disabled are not subjected to a limit of 5 debridements per wound.  What this amounts to is TrailBlazer is imposing a very rank rationing to the most vulnerable patients in our society.

Third, debridement is universally accepted among wound care physicians as beneficial to wound healing.  There is nothing in the wound care literature that arbitrarily limits the number of debridements per wound.  In fact, there is important literature that suggests that more frequent debridement yields better wound outcomes.

Finally, frequent debridement in a non-rationed fashion saves limbs and, therefore, saves Medicare money.  The small increase in total costs of wound care brought about by more frequent and prolonged debridements is more than offset by the prevention of amputation, hospitalization and use of antibiotics.  More patients heal their wounds and save their limbs, and Medicare spends less money.  Frequent and prolonged debridement is truly win-win for the patient and Medicare.

One of the most important points about the limitation of 5 debridements per wound is the way Medicare has administered this rationing of wound care.  Since TrailBlazer’s Wound Care LCD titled “Wound Care – 4S-150AB-R1” was effective on March 1, 2008, TrailBlazer has been all over the map on how it administers this rule of 5.  Sometimes the edits are set so that all debridements for the wound, even 11040 through 11042, are included in the 5 debridement limitation.  On other occasions, if there is more than one wound on a limb these wounds are grouped together and the limit of 5 is applied to them collectively.  Still at other times, the limit of 5 has been applied to a wound that healed and then reoccurred, suggesting that the limit of 5 debridements is for the life of the patient instead of the life of the wound.

Upon researching the appropriate methodology for TrailBlazer to deny these wound care services, it has become clear that Medicare’s current denial process violates several of their regulations.  It is our understanding that TrailBlazer has to maintain a post payment review for submitted charges.  What the means is, after 5 debridements (11043 and 11044) for a specific wound, Medicare is obligated to pay the submitted charge, then ask for medical necessity justification and then ask for recoupment if they feel the medical necessity requirement has not been met.  Currently Medicare, through edits, is denying the charge and forcing medical necessity to be proved at Appeal Level 1, QIC and then finally at an ALJ level.  It is clear that they have raised a barrier to billing to prevent debridement of wounds past an arbitrary number of 5; not based on the needs of the patient but rather for totally bureaucratic reasons.

Because Medicare’s position in regard to debridements, we have brought a complaint against TrailBlazer Health Enterprises, LLC asking them to comply with the LCD, and their regulations, for reimbursement of the 11043 and 11044 charges in compliance with their LCD Wound Care – 4S-150AB-R1 implemented March of 2008.  We state:

“Defendants’ Unlawful Automatic Denial of Debridement Claims in Excess of Five Per Patient.

1. Wolcott receives numerous apparently automated denials based on the frequency of services. For example, Defendants currently reject any claim by Wolcott for debridement services coded under CPT codes 11043 (tissue/muscle) or 11044 (tissue/muscle/bone) if the patient has had 5 prior debridements under these codes. Initially, Defendants denied claims for more than 5 debridements, even if they were rendered the same day to a patient with more than 5 wounds. Defendants eventually agreed to stop denying this small subcategory of claims, but they continue to automatically deny every other claim for a debridement under these codes if the particular patient has already received 5 debridements under these codes.

2. This practice is contrary to law. Automated denials can be made only when a “clear policy” or certain other conditions not relevant here exist. Medicare Program Integrity Manual, Ch. 3, § 3.5.1; Ch. 13, § 13.3. The term “clear policy” means a statute, regulation, National Coverage Determination (“NCD”), coverage provision in an interpretive manual, or LCD that specifies the circumstances under which a service will always be considered non-covered or incorrectly coded. Medicare Program Integrity Manual, Ch. 3, § 3.5.1. Absent such a “clear policy” setting forth a criterion which will always result in the denial of a claim, claims cannot be automatically denied. Here, there is no such “clear policy.” To the contrary, TrailBlazer’s Wound Care LCD (L26721) (see Exhibit K attached hereto) specifically allows payment for debridements billed under CPT codes 11043 and 11044 in excess of five per year so long as medical necessity is appropriately documented. In pertinent part, the LCD provides that:

Payment for prolonged, repetitive debridement services requires adequate documentation of complicating circumstances that reasonably necessitated additional services. Medicare expects fewer than five debridements involving removal of muscle and/or bone debridements to be required for management of most wounds. . . . Medicare will cover up to five surgical debridements, CPT code 11043 and/or 11044, per patient, per year. Services beyond the fifth surgical debridement, CPT code 11043 and/or 11044, per patient, per year, will be payable only upon medical review of records that demonstrate the medical  reasonableness and necessity. …

Therefore, even in the absence of a binding ALJ or MAC holding on point (see Section C, above), Defendants’ automatic denial (i.e., denial of all such claims without consideration of medical necessity) of more than five debridements is unlawful.

3.  Despite repeated requests by Wolcott, Defendants have refused to cease using this unlawful criterion.  There is no adequate administrative appeal process to challenge Defendants’ use of this unlawful criterion for automatically denying claims.”

If you agree with this lawsuit, please send your name and e-mail address to mcc@randallwolcott.com so we can be sure of your support. We feel that if the wound care community strongly voices its opinion, that limiting 11043 and 11044 debridements to 5 per wound is fundamentally wrong, maybe Trailblazer or their regulatory superiors will overturn this decision.