Medicare LCD

CMS established Local Coverage Determination (LCD) in section 522 of the Benefits Improvement and Protection Act of 2000 (BIPA 2000). In this policy change, all Local Medical Review Policies (LMRP) were converted to LCDs. The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) of the Act. Whereas LMRPs may have also contained other information such as coding and payment guidelines.

LCD codes are changed and updated on a regular basis. As most Physician and billing offices already know, ICD-10 is fundamentally changing medical claims management. In the case of LCDs, ICD-10 provoked a major overhaul of the code base that is still ongoing. One Medorizon Employee recently dealt with the side effects of these changes.

Here is her story:

“After the ICD-10 transition I downloaded and printed all of the LCDs that I use on a daily basis. These were printed on 10/21/15.

I then coded all of my facet joint injection procedures. The usual diagnosis that my provider uses is facet arthropathy which per the usual policy is M12.9. About 2 weeks later I started receiving denials stating that the diagnosis code does not meet LCD policy criteria.

I looked back on the website and the LCD policy was updated on 10/23/15 without warning, 2 days after I viewed and printed it. The updated code stated the correct diagnosis for facet arthropathy was M12.88.

I called NGS [The regional administrator of LCDs in Illinois] and asked them what was going on. The representative said that they updated the policy and that by the time the claims were received, the policy was using the new diagnosis of M12.88. So now I had to do reconsiderations for a significant amount of claims. This is when I learned to check the policies on a daily basis.”

At Medorizon we take proactive approach in offering continuing education to ensure our employees are well educated in all aspects of LCD as it is critical to timely claims reimbursement. We have found three highly important details concerning current Medicare LCD policies and general procedure:

    You can no longer get LCDs from your local MAC, you have to use the website.

    The LCD ID numbers are no longer the same, they have all been updated since the ICD-10 transition.

    While LCDs are typically updated on a monthly basis and or quarterly basis, they can be updated at random, thus it pays to check your LCDs frequently. 

Let Medorizon assist you in managing your LCD’s and watch your reimbursements soar. Medorizon is a comprehensive medical billing outsourcing service, providing everything from revenue cycle management to legal support. Our services are not typical of the quality offered by similar companies. Face to face interaction and close interpersonal relationships along with our premium customer service, sets us apart from our competition. You are invited to contact us today to facilitate a relationship for the future.

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Article Contributors - Medorizon, John Miller, Amanda Brodsky, Tyson Polack