Local Coverage Determinations are extremely important . . .
Although coding guidelines, National Coverage Determinations (“NCD”), and other coding resource texts are among the most important resources available to healthcare providers, Local Coverage Determinations (“LCD”) are equally as important.
Local guidance is often overlooked by practices without intuitive software to catch concerns when providing services for Medicare beneficiaries.
Even billing systems with the ability to ‘scrub’ claims for these edits, they are updated frequently and can change the outcome of a submitted claim. Local Coverage Determinations provide us with a more targeted look into the diagnosis considered medically necessary by the Medicare Administrative Contractor (“MAC”), for the jurisdiction in which the service was performed. The MAC is a private health care insurer that has been awarded a geographic area or “jurisdiction” to regionally manage the policies and medical claims for Medicare Part A and Part B beneficiaries.
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Cardiovascular Stress Testing – a great LCD example . . .
Cardiovascular stress testing is a good example to use to show the importance of LCDs. Currently, there are few NCD guidelines for cardiovascular stress testing, reinforcing the need to review the limitations imposed locally. For example, if a service is provided in Arizona, the coder would reference the ‘Who are the MACs’ page on the Center for Medicare and Medicaid Services (“CMS”) website to find out the MAC jurisdictions. Upon investigation, one will find that Noridian Healthcare Solutions is the MAC jurisdiction F including Arizona. This leads us to the Noridian Healthcare Solutions website after which will look for active LCDs for jurisdiction F.
Noridian Healthcare Solutions offers LCD L36889 for cardiovascular stress testing.
Link to LCD L36889 (click here)
What’s included as part of LCD 36889 . . .
- LCD 36889 provides a list of medically necessary diagnosis for which cardiovascular stress testing, including pharmacological stress and stress echocardiography, may be performed and reimbursed in jurisdiction F. Performing the test for a diagnosis not included in this LCD will most likely result in a claim denial.
- LCD 36889 also provides information for codes 93015, 93016, 93017, 93018, 93350, 93351, 93352, and many stress test related medications. Also included are add-on codes 93320, 93321, and 93325.
Who needs to know – coding, billing and provider . . .
LCD L36889 is provided as an example within this article, however there are hundreds of LCDs available to help reduce the risk of unnecessary procedures and services. A mistake often made by healthcare providers is assuming that only the coder needs to be aware of this information. Billing staff also need to be aware the policies are available. LCDs can be the cause of common denials and will ease communication with coding staff. Considering the provider would be ordering and/or performing the procedure or service, they too should be made aware of the specific LCD. Provide the education necessary to assure sure your staff is prepared to locate the MAC for your area and the LCDs for common procedures and services performed within your practice or hospital organization.
