Reader Question: Know Your LCD to Avoid Denials
Question: I've heard that the LMRP can help us avoid denials on laboratory diagnostic tests. What is the LMRP exactly? And how will it help us to avoid denials?
Illinois Subscriber
Answer: Until recently, each local Medicare carrier released an LMRP, or local medical review policy, to limit the diagnosis codes that would justify certain high-volume tests and procedures. However, effective Dec. 7, 2003, CMS began requiring fiscal intermediaries and carriers that contract with them to issue local coverage determinations (LCDs) instead.
"The difference between LMRPs and LCDs is that LCDs consist only of 'reasonable and necessary' information, while LMRPs may also contain category or statutory provisions," CMS states. The important thing to know is that during this transition, the terms "LMRP" and "LCD" refer to the same thing: local guidelines for when and how to bill for certain tests and procedures.
In addition to placing limits on the diagnosis codes that justify medical necessity for some tests and procedures, the LCD establishes billing guidelines for certain services and includes limits on frequency and patient eligibility. You should therefore obtain a copy of your local Medicare carrier's LCDs for the procedures you perform most frequently, and familiarize yourself with the limits and guidelines for services your office performs. Without this knowledge, you risk billing for services that are medically unjustified or over the allowable limit according to the LCD -- and the HHS Office of the Inspector General can view this as an attempt at billing fraud. Your office doesn't want to waste time performing and billing for a service that won't be covered.
For example: Trailblazer Health Enterprises LLC, a Part B carrier in Texas, has an LCD regarding continuous glucose monitoring. The determination lists six diagnosis codes that you can use to support medical necessity when you bill 95250 (Glucose monitoring for up to 72 hours ...) to the carrier:
To collect reimbursement from Trailblazer, you must report one of these six diagnosis codes and have the verifiable documentation to back up your claim. If you bill 95250 with a diagnosis code other than those listed, the insurer will deny your claim. Knowledge of your Medicare carrier's LCD, therefore, is the only way to proactively ensure that you are coding correctly and ethically for reimbursement and that your practice doesn't unknowingly perform noncovered services.
But although your LCD tells you which diagnosis codes it will reimburse, this doesn't mean you can report these codes without proper documentation. Coding from the record is the only way to stay safe in the event of an audit.
-- The answers to the Reader Questions and You Be the Coder were provided by Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C.; and Rhoda H. Cobin, MD, FACE, a clinical endocrinologist in private practice in Midland Park, N.J.
- Published on 2004-05-20
SuperCoder
