Ophthalmology and Optometry Coding Alert

Question: We recently learned that CMS is instructing the MACs to change the local coverage determinations (LCDs). Will this be happening across the board? And if so, what will the difference be?

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Answer: In an effort to streamline more of its processes, CMS offers new guidance on local coverage determinations (LCDs). The technology-forward updates include revisions to the Medicare Program Integrity Manual (PIM).

Context: The 21st Century Cures Act required certain adjustments to support greater “transparency” in regard to how LCDs are constructed, reviewed, and processed, according to a CMS fact sheet on the changes. The agency is implementing these requirements that will impact Medicare Administrative Contractors (MACs) by revising chapter 13 of the Medicare Program Integrity Manual.

Timeline: The LCD changes, which fall under CR 10901, are effective as of October 3, 2018with an implementation date of January 8, 2019, says Transmittal 829.

“With the new local coverage determination process, we are taking the first step toward clarifying and modernizing our coverage and payment policies,” said Seema Verma, CMS administrator, in a release. “We look forward to working with stakeholders on this and other initiatives that promote innovation and patient access.”

The new updates to the Medicare Program Integrity Manual stick to current patient-centered trends prevalent in other CMS policies. However, though the changes support more beneficiary involvement, health IT, and efficiency, the LCD policies could end up adding extra work for the MACs.

Here are five important takeaways from the CMS fact sheet summarizing the LCD updates:

1. Back it up. More of the onus will be on the MACs to defend their LCDs with evidence. The MACs will also show how they came to policy conclusions with a “step-by-step” process. They will also need to align their reconsideration policies with those of national coverage determinations (NCDs).

2.  Include the public. Beneficiary involvement is the pervasive theme of the LCD changes. Some of the options will be “informal meetings with MACs,” beneficiary reps on the Contractor Advisory Committees (CACs), publicized CAC meetings, and more discourse.

3. Request on demand. “A novel process by which interested parties in a MAC jurisdiction can request a new LCD,” noted the agency fact sheet.

4. Remove the codes. In the future, CPT^® codes and ICD-10-CM codes will not be part of LCDs. The summary does not go into the details on where these codes will be “relocated” to.

5.  Retire proposals. If proposed policies aren’t solidified within one year’s time, CMS advises the MACs retire them.

Note: Find a more in-depth look at the LCD changes’ fact sheet at www.cms.gov/newsroom/fact-sheets/summary-significant-changes-medicare-program-integrity-manual-chapter-13-local-coverage.