Master Core Curriculum

1. Master Core Curriculum Part B Intermediate Module 5 Local Coverage Determinations (LCD)

2. Learning Outcomes At the end of this module, participants will be able to: • describe the purpose of Local Coverage Determinations (LCDs) • correctly bill for services when LCDs apply • determine when to submit medical documentation with a claim, upon request • describe the LCD reconsideration process

3. Local Coverage Determinations (LCDs) • LCD is a formal statement developed through a specific process that: • Defines item/ service • Provides information about when a service is considered reasonaCarrier necessary • Outlines any coverage criteria and/or specific documentation requirements • Provides references upon which policy is based

4. LCDs • Local medical policies • Developed on a contractor-wide basis • Replace Local Medical Review Policies (LMRPs) • Provide decision-making criteria for claim review and payment decisions

5. LCD Policy Development • Carriers develop LCD in response to: • Absence of national policy • Need to apply a national (CMS) policy • Advent of new technology • Data analysis indicating need for an LCD

6. Carrier Advisory Committee (CAC) • Composed of: • Medical professionals within Medicare Program and medical community, • Carrier Medical Director, and • Other Medicare representatives • Draft LCDs presented and reviewed at CAC meetings • Process allows CAC to: • Comment of proposed medical policy prior to finalization • Provide objective review of policy

7. LCD Development Process • Draft LCDs available on Carrier’s Web site • Medical community has opportunity to provide input to contractor’s Medical Review department regarding drafted policy • After 45-day comment period, Carriers review comments and develop final policy • Final LCDs published on Carrier’s Web site • Implementation occurs at least 30 days after provider notification

8. Providers’ Responsibility • Providers are responsible for reading and knowing information in LCDs • Should keep and use LCDs as ongoing references • Improper billing may be considered a willful or fraudulent act • If contractor determines provider knew or should have known proper way to bill or utilize coding techniques

9. Proactive Measures Related to LCD • Review and read all Carrier physician publications and LCDs and become knowledgeable about coverage requirements. • Only submit documentation with claim when required by an LCD. • Ensure office staff and billing vendors are familiar with claim filing rules associated with LCDs.

10. Proactive Measures Related to LCD • Check records against claims billed. • Create an educational awareness campaign for Medicare patients to help them understand specific coverage limitations or medical necessity requirements for services provided. • Work with claim submission vendors to incorporate LCD edits. • Perform mock record audits to ensure that documentation reflects the requirements outlined in LCDs.

11. Documentation • Every service billed must be documented • Medical necessity must be substantiated • Services must be coded correctly • Documentation must indicate performing provider • Medical notes and records must be legible

12. LCD Reconsideration Process • Mechanism by which interested parties may request revisions to LCDs • LCD reconsideration requests are considered from: • Beneficiaries residing or receiving care in Carrier’s jurisdiction; • Providers doing business in Carrier’s jurisdiction; • Any interested party doing business in Carrier’s jurisdiction.

13. LCD Reconsideration Process • Carriers only accept reconsideration requests to LCDs published in final form • Request is invalid if modification of LCD would conflict with NCD • Requestor may review NCD reconsideration process at: http://www.cms.hhs.gov/manuals/108_pim/pim83c13.pdf

14. LCD Reconsideration Process • Requests should: • Be submitted in writing to local Carrier • Identify language that requestor wishes to change • Include justification supported by published evidence

15. LCD Reconsideration Process • Carrier will determine whether request is valid or invalid • If valid, Carrier will make final LCD reconsideration decision • Retiring policy • No revision • Revision to more restrictive policy • Revision to less restrictive policy • If LCD is revised, Carrier will follow normal LCD policy development process

16. Locating LCD’s • LCD’s may be located on: • Contractor’s Website Medicare Coverage Database at www.cms.hhs.gov

17. Locating LCDs

18. Chapter Review Slide • Review question….What is the purpose of an LCD? • Review question….Who may submit a request for LCD reconsideration?

19. Chapter References/Citations • CMS Manual System, Pub 100-8, Medicare Program Integrity, Chapter 13, Local Coverage Determinations