Coding

Ensure proper coverage

How to read and use Local Coverage Determinations.

BY PAUL M. LARSON, MBA, MMSC, COMT, COE, CPC, CPMA

When trying to determine if your patient has coverage for a service under Medicare Part B, you need to know about two important documents: your local carrier’s Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs). The LCDs were established in regulations in late 2003 and replaced the older, but different Local Medical Review Policy (LMRP) over the ensuing two years.¹ These newer documents delineate when a service, such as a surgery or diagnostic test (e.g., cataract surgery, visual fields), is covered and what documentation is required to support it. Equally important, while you might wish for guidance on a specific issue, it won’t always exist.

Medicare itself will sometimes issue high-level guidance via the National Coverage Determinations (NCDs), which all Medicare Administrative Contractors (MACs) must follow from the effective date until they are retired or rescinded. NCDs for eye-care services are not common, but they deal more often with “big picture” national issues, while LCDs and LCAs typically are more specific and local.

Remember that under Medicare Part B, there is no “prior authorization” option — your office is responsible for knowing whether something is covered. Of course, some clinical situations are unclear. When there is doubt, an Advance Beneficiary Notice (ABN) may be needed to notify the Medicare beneficiary and get acknowledgement of responsibility in advance (see tinyurl.com/OPCodingMay16).

Decide if a service is covered

First, a service (diagnostic test, major or minor surgery, examination) must be medically necessary and properly documented to be covered. Second, if an LCD or LCA exists in a particular region, it governs coverage for that region by listing the circumstances the local MAC feels are warranted for coverage then provides guidance on chart documentation requirements and limitations. It is possible to have different rules in different states — the NCD is national and always rules if there is conflict (this is rare). MACs list their LCDs on their website; they are available for downloading and printing.

You can also use the “Quick Search” feature in the upper right of the Medicare Coverage Database website to find your local documents.² You can search by the “Document ID” or by “Document type” (this is by far the easier route when not knowing if there is a document or its number). If searching by “Document type,” you need to know:

• Whether you want to search by NCD and LCD, NCD only, or LCD (the most common)

• The Geographic Area/Region

• The CPT code for the service.

It’s possible to search by keyword as well, but this can be difficult if you don’t know the exact title of the document. After entering the information, click the “Search by Type” button. If there is a current document, you will see it listed. You can link to the document(s) via the blue hyperlink of the document ID (on the left) and must scroll down to the “Accept” button and click it to view the current LCD.

Know how to use the LCD

For an example, I will use a search for the LCD for OCT (CPT 92134) in the state of Michigan (you can follow at tinyurl.com/OPCodingSept16). After inputting the above information, you should be able to view the document (LCD No. L34760). The areas covered are listed first. If you scroll down, you will see the following:

• Coverage Guidance

• Coding Information (what CPT and ICD-10 codes apply for this document).

• General Information

• Revision History

• Associated Documents

1. ◦ Indications, or the reasons you might do it.

   ◦ Limitations on coverage (this shows some MAC concerns related to CPT codes 92250, 92225, 92226, and 76512).

   ◦ For 92134, scroll down to “Group 3 Paragraph” for the diagnosis codes that should provide coverage if your charts make the case for medical necessity (261 diagnosis code entries). Group 1 deals with CPT 92132, and Group 2 is for 92133.

   ◦ Documentation and utilization guidelines.

   ◦ Sources of information used by the MAC to develop and support their policy.

   ◦ Any changes over time to the LCD and the reasons for those changes.

   ◦ This document has a “Billing and Coding Guidelines” link as well (not all do).

   ◦ In some LCDs, this area has a link to a LCA with more specifics on certain clinical situations. (This document does not have one.)

   ◦ Links to the LCD in effect for other date ranges of service if the document had changes. Only the revision in effect when your office actually delivers the service applies, so when appealing denials you must use the document in effect when you delivered the service.

Conclusion

Knowing whether a coverage document exists is a crucial element in knowing if the services your patients want or need will be covered on the date you deliver them. It’s also important that you keep, save, or know how to find them, since NCDs, LCDs, and LCAs are periodically revised. Use them to help decide if there are coverage and limitations.

Remember that not every service you deliver will have a coverage guidance document — in those cases, proper documentation of medical necessity is key. OP

REFERENCES:

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.