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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, September 14, 2012 Posted in: Inpatient Rehab

Hot off the press from healthcare associations around the United States:

Cahaba Rescinds Proposed LCD  “Surgery: IRF Admission after Single Joint Replacement with CMGs A0801-A0806.”

American Medical Rehabilitation Providers Association (AMRPA), and many other associations, successfully halt an LCD that would further reduce beneficiary access to inpatient rehabilitation (IRF/U),  levels of care after single joint replacement procedures.

The points made by AMRPA, the Missouri Hospital Association and The Coalition to Preserve Rehabilitation (CPR) of the Association of Rehabilitation Nursing along with more than 20 other coalitions, agencies and advocates for rehabilitation signed numerous documents to educate Cahaba on the reasons the LCD  should not be made active.

“Missouri Hospital Association sent a letter to Cahaba last week, urging Cahaba to withdraw a proposed local coverage determination that would deny coverage for admissions with single joint replacements without co-morbidities for case mix groups between A0801 and A0806. Cahaba announced today that they are rescinding the LCD, and it will not be finalized. This is a great outcome to a potential limitation of patient access.”

Each of the letters outlined details discussing the harmful reduced beneficiary access based on diagnosis alone, and inappropriate need for this type of LCD by citing some of these other facts:

  • The proposed LCD conflicts with federal regulations.
  • Cahaba’s proposal would impermissibly supersede CMS’ regulatory requirements by denying coverage of patients solely based on their case-mix group.
  • LCD runs counter to Medicare’s policy and payment standards.
  • The proposed LCD, which categorically designates patients in case mix groups A0801 – A0806 as not medically necessary, contradicts both the letter and spirit of the Medicare Benefits Policy Manual and physician-driven medical necessity recommendations.
  • LCD effectively would eliminate any role for physician judgment.
  • LCD is incongruous with IRF payment standards.
  • The Medicare Program Integrity Manual states that “[t]he contractor shall ensure that all LCDs are consistent with all statutes, rulings, regulations, and national coverage, payment and coding policies” in Chapter 12 § 13.1.13.

Every IRF can celebrate and be thankful for that victory!   Thank you to each of the different professional organizations that went to bat on this particular issue!