Oncology & Hematology Coding Alert

Question: One of my colleagues said that Medicare is changing LCDs to eliminate ICD-10-CM codes. Do we still need to list a diagnosis to show medical necessity for procedures and services?

Ohio Subscriber

Answer: CMS’s change to Local Coverage Determinations (LCDs) does not release you from documenting medical necessity for any medical procedure. Instead, this change involves the process for creating and presenting LCDs, not omitting a supporting diagnosis supporting the medical necessity of the service.

According to MLN Matters 10901, CMS used recent Medicare Physician Fee Schedule (MPFS) feedback to revise the Local Coverage Determination (LCD) process. The revamp includes new timelines, more consultation options, a different request mechanism, and more. Medicare Administrative Contractors (MACs) have a year to finalize or retire all LCD proposals.

Coding:  Regarding your question, CMS is changing how the agency expects MACs to provide coding information in the LCDs. The MLN Matters release states, “Upon further notice from CMS, it will no longer be appropriate to routinely include CPT^® codes or ICD-10-CM codes in the LCDs. All codes will be removed from LCDs and placed in billing & coding articles that are linked to the LCD,” CMS said.

Bottom line: You’ll still have diagnosis guidelines for medical necessity based on LCDs. Only the format for where you’ll find those guidelines, and perhaps codes when applicable, is changing.

Resource: For more information on the LCD changes, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.