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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). |