Question

1. Who creates NCD's and LCD's?

1. Locate a current NCD, provided the tile and effective date.

1. Locate a current LCD, provide the title and effective date.

Answer 1

NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers.

NCD — NATIONAL COVERAGE DETERMINATIONS

Medicare specific coverage on the national level. All Medicare carriers are required to follow the NCDs. The NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an item or service is considered to be covered (or not covered). NCDs are usually issued as a program instruction. Once published in a Centers for Medicare and Medicaid Services (CMS) program instruction, an NCD is binding on all Medicare carriers.

LCD — LOCAL COVERAGE DETERMINATIONS

LCDs are always based on medical necessity and created by a carrier whether to cover a particular service. They only apply to the area served by the contractor who made the decision. LCDs determine as to whether the service or item is reasonable or necessary. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD.

Medical coders and billers have two types of coverage determinations within Medicare, local and national. When a contractor or fiscal intermediary makes a ruling as to whether a service or item can be reimbursed, it is known as a local coverage determination (LCD). When CMS makes a decision in response to a direct request as to whether a service or item may be covered, it’s known as a national coverage determination (NCD).

NCDs identify items and services that will be covered by Medicare. These items and services are considered reasonable and necessary in the treatment of an illness or injury and are identified as a Medicare benefit for all beneficiaries. All local contractors must pay for services as outlined in the NCD. NCDs are developed through an evidenced-based process that includes CMS research supplemented by external technology assessments and consultations as well as public participation. When reviewing NCDs, you should also look for additional LCDs and articles from your local contractor, as the NCD is a minimum coverage requirement. The local contractor may further define the same service; including specifying what diagnoses will support or negate coverage.

The outline of information found in NCDs is:

• Tracking Information: publication number, relevant Manual section, version, effective date, implementation date
• Description Information:
  • Benefit Category
  • Item/Service Description
  • Indications and Limitations of Coverage
  • Cross References
  • Claims Processing Instructions
• Transmittal Information, including a link and all revision history
• National Coverage Analyses, such as current review schedule and associated policy documents
• Additional information, such as prior versions

LCDs were defined in the Social Security Act Section 1869(f)(2)(B) which states “the term ‘local coverage determination’ means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary or carrier-wide basis under such parts, in accordance with section (a)(1)(A).” In other words, the LCD identifies if and when a service is reasonable and necessary. The contractor communicates specific covered and non-covered diagnoses in the LCDs Medicare Contractors are also given the discretion of determining any additional benefits that will be covered at the local level beyond what is already required based on NCDs. The additional benefits for services and items, and the terms by which such service will be considered reasonable and necessary, is communicated via LCDs. LCDs can address coverage requirements for items for services for which there is no NCD. The topics and coverage requirements may vary from contractor to contractor.

The outline of information found in LCDs:

• Document information: ID, Title, effective dates
• National coverage policy, including reference to any applicable CMS publications
• Coverage Guidance, including
  • Abstract of outlined services,
  • Coverage indications,
  • Limitations and/or medical necessity
• Coding information
  • Relevant CPT/HCPCS codes,
  • ICD-10 diagnosis codes that support medical necessity,
  • ICD-10 diagnosis codes that do not support medical necessity
• General information
  • Documentation requirements
  • Appendices
  • Utilization guidelines
  • Sources of information and basis for decision
• Revision history
• Associated documents
• Keywords