Association for Molecular Pathology                       
Newsletter                                                                
   
May 2009, Volume 15, Number 2 

Inside this Issue

Front Page
President's Message
Committee Reports
• Clinical Practice Committee
• Economic Affairs Committee
• Membership & Professional
  Development Committee

• Nominating Committee
• Professional Relations Committee
• Program Committee
• Publications Committee
• Training & Education Committee
Subdivision Reports
• Genetics
• Hematopathology
• Infectious Diseases
• Solid Tumors
Special Features
• AMP Leadership Award
• CHAMP

• Member Survey Report
• Web Editorial Board Report
• Show Me the Money!
• Announcements
• Career Opportunities
• Meetings and Upcoming Events
2009 AMP Officers and Appointees

Show Me the Money!
By Jeffrey A. Kant, MD, PhD
Chair, Economic Affairs Committee


National and Local Coverage Decisions

Medicare coverage is limited to services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Two types of coverage determinations exist.

National coverage determinations (NCDs) are binding on all Medicare contractors.  Laboratory NCDs contain a description of the services covered (or not covered) including eligible and noneligible ICD-9-CM diagnosis codes as well as CPT/HCPCS codes.  NCDs are kept current and updated as necessary quarterly by CMS with those updates published in the NCD Coding Policy Manual with general and specific coding guidelines.  The Manuals are available electronically: http://www.cms.hhs.gov/CoverageGenInfo/04_LabNCDs.asp).  After development, NCDs are posted on the CMS website for a 30-day public comment period, and a final decision is issued not later than 60 days after conclusion of the comment period.  A summary of public comments and responses to comments is included in the final NCD.  NCDs are typically made through an evidence-based process, with opportunities for public comment. CMS information and research may be supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).  For NCD requests which require an external technology assessment or Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) review, decisions are made not more than 9 months after the date the completed request was received.  For those which do have this requirement, decisions are made not more than 6 months following the request.

In the absence of a national coverage policy, an item or service may be covered at the discretion of Medicare contractors based on a Local Coverage Determination (LCD; http://www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp).  The vast majority of Medicare coverage is provided via LCDs.  An LCD is a decision by a fiscal intermediary or carrier whether to cover (or not) a particular service, again with a description of those services including eligible and noneligible ICD-9-CM and CPT/HCPCS codes.  LCDs are developed using literature, advice of local medical societies and practitioners, public comments, and comments from the provider community including Contractor (sometimes called Carrier) Advisory Committees (CACs).  LCDs contain only reasonable and necessary language. Any non-reasonable and necessary language a Medicare contractor wishes to communicate is done through an accompanying policy article, with a link to the article provided at the end of each LCD.  Local Medical Review Policies (LMRPs) which co-existed for a time with LCDs have now all been converted to LCDs.

The Medicare Coverage Database (MCD) contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local policy articles, and proposed NCD decisions.  The Database is updated in ‘real time’ except for NCD and LCD downloads which happen weekly.  The Database also includes potential NCD Topics, national coverage analyses (NCAs), coding analyses for labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MedCAC) proceedings, and Medicare coverage guidance documents.  Other useful information can be found under various subtopics at the Medicare Coverage Center (http://www.cms.hhs.gov/center/coverage.asp).