"Change is a constant" is not just an overused phrase, but rather an everyday reality. As the health care industry attempts to battle rising costs and insure appropriate coverage for beneficiaries, guidelines, and regulations are becoming more specific and restrictive.


The Centers for Medicare & Medicaid Services (CMS) has begun the process of combining previous individual Fiscal Intermediaries & Carriers into 15 Medicare Administrative Contractors (MACs) for both Part A and Part B. The administration of Medicare claims processing and related functions of the Medicare program are being awarded in a competitive bidding process. The intent was to centralize information and create a more uniform platform in the delivery of care.


The new A/B MACs will be required to develop an integrated and consistent approach to medical coverage across its service area. The Local Coverage Determinations (LCDs) are being combined and thus far they are adopting the more restrictive, clearly defined, directives for therapy intervention.


What does this mean for therapists providing intervention to Medicare beneficiaries with dementia and Alzheimer's?

  • We must be aware of the LCDs of our new MACs regarding therapy services. These will include descriptions of appropriate use of each CPT code and often list the ICD-9 diagnoses that support medical necessity.
  • You can find these MAC groupings by going to your previous Intermediary's website and they will indicate their new name, if it has changed.
  • You can search for therapy-related LCDs under such terms as physical medicine and rehabilitation, your discipline, or specific procedures. A link to all Medicare Coverage Determinations is provided at the end of this article.

The most notable MAC LCD is from National Government Services. NGS is the uniting of Empire, Adminastar, Mutual of Omaha, Anthem, and United Government Services. In the latest LCD (L26884), the use of 97532, Development of cognitive skills to improve attention, memory, problem solving has been limited to only 3 ICD-9 codes:

  • 310.1 Personality change due to conditions classified elsewhere.
  • 310.8 Other specified nonpsychotic mental disorders following organic brain damage.
  • Unspecified non-psychotic mental disorder following brain damage.

As mentioned in other articles, the use of 97532 has always been limited to the ability of the person to re-learn. The referenced NGS LCD does also provide interpretation of this determination:


"Cognitive skills are an important component of many tasks, and the techniques used to improve cognitive functioning are integral to the broader impairment being addressed. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and, typically are better reported using other codes (such as 97535)."


NGS also limits visits and # of units/visits for many of their CPT codes.


All MACs include and adhere to CMS regulations, including the Part B Exceptions Process. While allowing medically necessary therapy interventions to exceed the Part B financial limits, MACs may be more restrictive in the approaches. It remains imperative to document interventions with functional outcomes that defend the medical necessity in a reasonable time frame.


The Alzheimer's and Dementia ICD-9 codes are not listed in the LCDs that include medical conditions to support medical necessity. They are listed in the Part B exceptions list with indications as to whether or not they are "complexities" that must accompany other medical or treatment diagnoses. That list which has not changed since 2007 is included for you as a reference.


Serving those with cognitive impairment requires first of all the understanding of those conditions and the skilled specific training you have received from Dementia Care Specialists. This service then also requires an understanding of the health care provider's benefit regulations. The combination of both knowledge sources comes together in your defensive documentation.


Be specific with the abilities discovered and realized as you work with the person, caregiver, and environment. Emphasize the reasonable and medically necessary psychological and physical health benefits for both the person and caregiver. The CMS intent in restructuring the organization of those who implement the Medicare program was not only for greater efficiency in processing claims, but also to preserve the integrity of the Medicare Health Benefit provisions.


Being a leader in health care reform and implementation is in your hands and heart.


Link to Medicare Coverage Determinations: http://www.cms.hhs.gov/mcd/overview.asp


Medicare B Therapy Cap Exceptions listed on next three pages.