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What’s in a Name? Defining and Understanding Local Coverage Determinations
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Though it’s a far cry from the infamous feud between the Montagues and Capulets, there can be an occasional conflict on exact coverage policy between physicians and Medicare Part B payers. To help you avoid becoming part of such conflicts, here’s a quick guide to local coverage determinations (LCDs).

What is a LCD?
Each Medicare contractor has the discretion to establish which services are considered reasonable and necessary, and therefore paid as a Medicare benefit. When finalized, these are the rules and regulations by which physicians are held accountable in an audit.

undefinedThere are three stages of LCDs.

1. Draft LCDs. Once developed, typically in conjunction with the carrier advisory committee members, the Medicare contractor must provide a comment period and a notice period with the establishment of:

  • A new LCD;
  • The revision of an existing LCD that is more restrictive; and
  • The revision of an existing LCD that involves a substantive correction. 

The draft, posted on the payer website, allows 45 days for comment. During this period, Medicare solicits comments and recommendations from a wide range of individuals and organizations. After comments are received and any revisions made, the final LCD must be posted with a minimum notice period of 45 calendar days.

2. Final (Active) LCDs. Each final LCD has an effective date and a distinct coverage area. Typical LCDs include a description of each covered service, documentation requirements and information regarding the ICD-9 codes that do or do not support medical necessity. 

To find the LCDs specific to your state, visit your local Medicare Part B website. You can also view the policies from each state by visiting the Medicare coverage database.

3. Retired LCDs. Medicare contractors are required to archive retired LCDs. They can be useful as a guide.

What Ever Happened to LMRPs? 
Effective Dec. 7, 2003, CMS began issuing LCDs instead of Local Medicare Review Policies (LMRPs). Over the next two years, Medicare contractors converted all existing LMRPs into LCDs and articles.

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About the author: This article originally appeared in the August 2011 issue of Coding Bulletin. It was written by Academy Coding Executive Sue Vicchrilli, COT, OCS.

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