Urology Coding Alert

Question: We have differing opinions in our office about whether we should follow NCDs, LCDs, or both. What’s the difference between the two? Which do we go by?

Washington Subscriber

Answer: Local coverage determinations (LCDs) and national coverage determinations (NCDs) both are important to your coding and billing success. They each can have different information from the other, which means you should probably check both for a particular service before you file the claim.

“The vast majority of coverage is provided on a local level and developed by clinicians at the contractors that pay Medicare claims in the form of local coverage determinations, or LCDs,” said CMS’s Lauren Robbins during CMS’s webinar, “Medicare Basics, Part Two.” “However, in certain cases, Medicare deems it appropriate to develop a national coverage decision, or NCD, for an item or service to be applied on a national basis for all Medicare beneficiaries meeting the criteria for coverage.”

Know the difference: An NCD is a national policy that stems from the evidence based determination that a particular item or service is reasonable and necessary. The public may request it or it may be internally generated by CMS and have opportunities for public participation. In some cases, CMS’s own research is supplemented by an outside technology assessment and/or consultation with the Medicare evidence development and coverage advisory committee (MEDCAC).

Medicare contractors develop LCDs for their jurisdictions when there is no NCD or when there is a need to further define an NCD. A local policy may consist of two separate documents, the LCD and an associated document. At the end of an LCD that has an associated article, there is a link to the related article and vice versa. All providers should be knowledgeable about Medicare coverage prior to providing services or items to a Medicare beneficiary.

Resource: The searchable Medicare Coverage Database contains all NCDs, LCDs, proposed NCD decisions, national coverage analyses, coding analyses for labs, local articles, MEDCAC proceedings, technology assessments and Medicare coverage guidance documents, Robbins added. You can access it at www.cms.hhs.gov/mcd.