Orthopedic Coding Alert

Question: What’s the difference between a national coverage determination (NCD) and a local coverage determination (LCD), besides the obvious difference in scope?

Nevada Subscriber

Answer: One big difference between NCDs and LCDs is the way that they’re developed.

According to the Centers for Medicare & Medicaid Services (CMS), LCDs are developed by Medicare Administrative Contractors (MACs), and NCDs are established by CMS.

In a document about Medicare Coverage Type Descriptions, CMS says LCDs are decisions made by MACs “on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees. … LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. Before an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period.” MACs develop LCDs for a topic or service in the absence of an NCD. More than one MAC may manage services based on a single LCD criteria.

LCDs can differ between MACs, which means an LCD may really be local. Therefore, it’s important to check with your MAC’s determinations directly to make sure you’re in compliance.

CMS describes NCDs as national policies developed and released by CMS establishing the Medicare coverage for specific medical items or services across all states. MACs are required to follow NCDs, and NCDs trump LCDs. There won’t be any difference in determinations between jurisdictions, because the coverage is national.

Check out the CMS website for more about different Medicare coverage types.