{"id":78,"date":"2020-02-29T20:39:38","date_gmt":"2020-02-29T20:39:38","guid":{"rendered":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/?p=78"},"modified":"2020-02-29T20:39:38","modified_gmt":"2020-02-29T20:39:38","slug":"frequently-asked-questions-liposuction-for-lipedema-reimbursement","status":"publish","type":"post","link":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/frequently-asked-questions-liposuction-for-lipedema-reimbursement\/","title":{"rendered":"Frequently Asked Questions: Liposuction for Lipedema Reimbursement"},"content":{"rendered":"\n

This document is an adjunct<\/em> to the Liposuction\nfor Lipedema Overview<\/em>; a lot of the information is the same except it is\nformatted differently and the slant here is to specifically address\nmisperceptions, vague terms, and how precise language and consistency are\nimportant to win appeals. Or goal is to gain widespread acceptance for Lymph-Sparing,\nTumescent Liposuction (LS-TL) as a medically necessary treatment for Lipedema\nworldwide.<\/p>\n\n\n\n

Q:\nIsn\u2019t Lipedema<\/strong> the same as Obesity?<\/strong> No, it is a\ncondition in which there is a pathological deposition of fatty tissue, usually\nbelow the waist, leading to progressive leg enlargement. Lipedema is often\nmisdiagnosed as simply obesity or lymphedema. There is no cure for lipedema<\/em> and it\ndoes not respond well to diet and exercise.<\/em><\/p>\n\n\n\n

Q:\nIsn\u2019t Liposuction a Cosmetic Procedure?<\/strong> I just read on a board-certified surgeon\u2019s website that \u201cliposuction\nis a cosmetic procedure and never reimbursed by medical insurance.\u201d I would\nthink they know more than you! <\/p>\n\n\n\n

Answer:<\/strong> Not in regard to reimbursement. Performing a procedure has nothing to know with the dozens of issues regarding coding, documentation, carrier policies, and reimbursement. While a common belief, this is an inaccurate statement; most people simply think of liposuction as a cosmetic, body-contouring procedure. It is not i<\/em>n the Medicare fee schedule (no RVU\u2019s) which means there is no generally-accepted reimbursement value for the four liposuction codes. Most doctors are not familiar with and do not confirm a lipedema diagnosis, and finally some surgeons either don\u2019t know how or <\/em>don\u2019t want to file medical insurance for the procedure: they will earn less from medical carrier reimbursement.<\/p>\n\n\n\n

Old Habits die Hard:<\/strong> Websites, doctors, associations, blogs and the general public general think of and refer to liposuction as an \u201caesthetic\u201d and cosmetic procedure. However for a diagnosis of lipedema it is reconstructive. This has very important legal and reimbursement implications. See the question below on documentation on how to demonstrate it as reconstructive.<\/p>\n\n\n\n

Q: I was told that all\/most carriers won\u2019t pay so why bother filing a claim?<\/strong> Three reasons: one is that some carriers (Anthem) have a payment policy, others have paid (estimates as high as 30% reimburse after multiple appeals), and last: if there is a class action suit against the carrier and it is won, you may be entitled to reimbursement even if your surgery was one or two years prior (depends on the exact wording of the settlement). If you never filed insurance you won\u2019t be eligible. Also you may need to file at least one appeal (recommend at least two). Those who have won appeals typically win after the second attempt.<\/p>\n\n\n\n

Q: What is Medical Necessity?<\/strong> This has connotations clinically and administratively. In terms of reimbursement any medical service or procedure must be supported by medical necessity (the conditions or disease, severity, and progression) to support the use and subsequent reimbursement for the procedure. A service may be medically warranted for the benefit of the patient (meets medical guidelines) but does not meet the carrier\u2019s guidelines as being \u201cmedically necessary\u201d. Therefore a service\/procedure could be denied as not medically necessary because:<\/p>\n\n\n\n

  1. Not FDA approved.<\/li>
  2. The patient is too sick for the procedure (comorbidities) and the risk to the patient was not addressed. <\/li>
  3. Experimental or Investigational (these are generally used interchangeably).<\/li>
  4. Unproven is related to the reason terms above, but some carriers view it differently. For example, a procedure may be used widely and have decades of use, so it would no longer be considered experimental or investigational; the carrier simply doubts the efficacy and value of the procedure for treatment of a particular condition or disease).<\/li><\/ol>\n\n\n\n

    Reconstructive\nsurgery<\/strong> is approved if it is\nto \u201cimprove the function of a malformed body part.\u201d [Medicare National Policy, MAR\n2020]. Liposuction will be approved for lipedema if the insurance is convinced\nit is (1) medically necessary and not (3) investigational\u201d<\/strong>\nor \u201cexperimental<\/strong>\u201d or \u201cunproven<\/strong>.\u201d It must meet both hurdles.\nSome carriers (e.g., United Healthcare) consider \u201cunproven\u201d as different from\nthe other two (others don\u2019t).<\/p>\n\n\n\n

    Q:\nWhat is \u201cinvestigational\u201d or \u201cexperimental\u201d or \u201cunproven?\u201d<\/strong><\/p>\n\n\n\n

    Per Blue Cross and Blue Shield Association’s\nMedical Advisory Panel:<\/p>\n\n\n\n

    \u201cA treatment is considered investigational or\nexperimental when it has progressed to limited human application, but has not\nachieved recognition as being proven effective in clinical medicine.\u201d<\/p>\n\n\n\n

    The Knox Keene Act (CA) has a rather strict\nview of what would be allowed regarding an \u201cinvestigational\u201d or \u201cexperimental\u201d\nor \u201cunproven\u201d procedure:<\/p>\n\n\n\n

    \u201cThe patient has a life threatening or\nseriously debilitating disease which is expected to cause death within one year\nin the absence of effective treatment; the clinical trial has been approved by\nan Institutional Review Board (IRB) that will oversee the investigation;<\/p>\n\n\n\n

    United HealthCare Insurance Company uses an\nexclusion in its medical policies for treatments it considers \u201cExperimental or\nInvestigational.\u201d The investigational definition merely requires that the\ntreatment have approval from an appropriate regulatory body such as the FDA<\/p>\n\n\n\n

    Q:\nHow should the documentation look?<\/strong><\/p>\n\n\n\n

    It is imperative that Providers use verbiage\nthat explains\/reinforces that liposuction for lipedema is a reconstructive and that\nit:<\/p>\n\n\n\n

    1. Restores the patient to a normal <\/em>appearance. [emphasis on restore\n\u2026 to normal]. Use the term \u201cmalformed body part\u201d.<\/li>
    2. Improves function [ability to walk, mobility].<\/li>
    3. Improve the patient\u2019s quality of life.<\/li>
    4. Based on evidence-based\nguidelines and research<\/em>, liposuction is the only procedure available after\nall conservative treatments for lipedema have been exhausted.<\/li><\/ol>\n\n\n\n

      It must also be documented and demonstrated\nto the medical insurance company the patient has completed conservative\nnon-surgical treatment of lipedema without\nadequate relief<\/em> of their lipedema symptoms. Also demonstrate that no comorbidities<\/em> preclude the surgery.<\/p>\n\n\n\n

      Q:\nWhat verbiage should I avoid?<\/strong>\nAvoid using terms such as \u201ccontouring\u201d, \u201cimprove appearance\u201d, \u201caesthetic\u201d or\n\u201ccosmetic liposuction\u201d in all Provider notes and pre-authorization letters. <\/p>\n\n\n\n

      I would avoid psychological benefits as most\nmedical health insurance policies specifically state that \u201cfeeling better about\nyourself\u201d is not a valid, medically necessary reason for a procedure. Most\ncosmetic procedures make \u201cyou better feel better\u201d. It is best to avoid that\ncomparison.<\/p>\n\n\n\n

      Be sure to include pictures and focus on\nfunction, mobility, progression of the disease, and the \u201cdeformity\u201d of the\ncondition.<\/p>\n\n\n\n

      Q:\nI was told there are no ICD-10 codes for lipedema. Is that accurate?<\/strong><\/p>\n\n\n\n

      Currently (MAR 2020), There is no ICD-10-CM diagnosis code specific to\nLipedema. After reviewing this problem, I\u2019ve identified three ICD-10-CM codes\nused in the USA for lipedema. Each one has its problems. <\/p>\n\n\n\n

      R60.9\nEdema  [This is a Sign and Symptom code]<\/p>\n\n\n\n

      Q82.0\nFamilial Hereditary Edema      [All \u201cQ\u201d\ncodes are considered hereditary\/congenital]<\/p>\n\n\n\n

      E88.2:\nAdiposis dolorosa; Lipomatosis dolorosa (Dercum\u2019s disease) [An \u201cE\u201d code is an\nendocrine system code]<\/p>\n\n\n\n

      I would recommend R60.9 first and Q82.0 second. The E88.2 is related to the German ICD-10 codes but the \u201cdolorosa\u201d are distinctly separate conditions from lipedema. Note how each code is from a different section of ICD-10. Each one has drawbacks\u2013the most important issue here is that we cannot specifically track lipedema as a unique condition. We urgently need a specific code for lipedema.<\/p>\n\n\n\n

      Q:\nI was told to submit the liposuction for lipedema procedure with CPT code 38999\n(unlisted procedure, hemic or lymphatic system). Is that correct?<\/strong><\/p>\n\n\n\n

      I do not recommend this. Using an unlisted code adds another level of complexity toward obtaining reimbursement. Unlisted codes are rarely reimbursed. It also reinforces the idea that the procedure is experimental and investigational\u2013because there is no code for it! There are currently (2020) four liposuction CPT codes: (15876, 15877, 15878, and 15879).They have no Medicare RVU\u2019s (there is no Medicare fee schedule for them). [More information is available in CPT Coding for Liposuction for Lipedema]<\/a>.<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

      This document is an adjunct to the Liposuction for Lipedema Overview; a lot of the information is the same except it is formatted differently and the slant here is to specifically address misperceptions, vague terms, and how precise language and consistency are important to win appeals. Or goal is to… Continue reading → <\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[33],"tags":[41,42],"class_list":["post-78","post","type-post","status-publish","format-standard","hentry","category-reimbursement","tag-faq","tag-frequently-asked-questions"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts\/78","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/comments?post=78"}],"version-history":[{"count":1,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts\/78\/revisions"}],"predecessor-version":[{"id":79,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/posts\/78\/revisions\/79"}],"wp:attachment":[{"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/media?parent=78"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/categories?post=78"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/12uh.com\/lipoforlipedemareimbursement\/wp-json\/wp\/v2\/tags?post=78"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}