Wiki Is Medicare LCD based on where patient lives or where service is provided?

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jamesbzn

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My understanding is that the Medicare LCD for a given procedure is based on where the procedure is performed, such that, for example, if a patient lives in Novitas jurisdiction, but travels to and has a procedure performed in a Palmetto jurisdiction, the medical necessity for the procedure would be based on the Palmetto LCD. Can someone confirm this is correct?

Secondly, and more importantly, where is the Medicare rule that says LCD policy is based on where the service is performed as opposed to where the patient lives?
 
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jamesbzn said:
Yes, this is very helpful. But I need to find something in writing. Perhaps another way to approach this is to find the regs that talk about which MAC gets billed. Is there a Medicare manual or other regulation that says Medicare claims are sent to the MAC where service was provided versus where the patient resides? For example if patient lives in DC (Novitas) and has a procedure performed in VA (Palmetto), what is the regulation that says provider must send the Claim form to Palmetto? What if the Provider has offices in both DC and VA?
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Have you ever tried to bill a MAC that you are not contracted with? If your provider has an office in DC, then that office location would be on the contract with that MAC. The other office would be on contract with the other MAC.

Medicare: "Medicare area carriers typically process Part B fee-for-service claims for services furnished in specific geographic areas (e.g., a State). However a single carrier processes all physician/supplier claims for railroad retirement beneficiaries. (See §10.1.3 for claims for Part B medical services performed outside the U.S. for individuals who reside in the U.S.). "

Same link: "The jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is governed by the payment locality where the service is furnished and will be based on the ZIP code."

Also, same link: "Effective for claims received on or after April 1, 2004, A/B MACs (Part B) must use the ZIP code of the location where the service was rendered to determine A/B MACs (Part B) jurisdiction over the claim and the correct payment locality. Effective for dates of service on or after October 1, 2007, except for services provided in POS “Home,” if they are not already doing so, A/B MACs (Part B) shall use the CMS ZIP code file along with the ZIP code submitted on the claim with the address that represents where the service was performed to determine the correct payment locality."

Again, same link: "When a physician, practitioner, or supplier furnishes physician fee schedule or anesthesia services in payment localities that span more than one A/B MAC (Part B)’s service area (e.g., provider has separate offices in multiple localities and/or multiple A/B MACs (Part B)), separate claims must be submitted to the appropriate area A/B MACs (Part B) for processing. For example, when a physician with an office in Illinois furnishes services outside the office setting (e.g., home, hospital, SNF visits) and that out-of-office service location is in another A/B MAC (Part B)’s service area (e.g., Indiana), the A/B MAC (Part B) which processes claims for the payment locality where the out of office service was furnished has jurisdiction for that service. It is the A/B MAC (Part B) with the correct physician fee schedule pricing data for the location where the service was furnished. In the majority of cases, the physician fee schedule or anesthesia services provided by physicians are within the same A/B MAC (Part B) jurisdiction that the physicians’ office(s) is/are located. "


Is that what you're looking for?
 
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You are correct, the payment rules govern the region where the services are provided, not where the patient lives. I don't know where you can find documentation to this effect, but think of it this way - the Medicare program has delegated authority to set make certain payment decisions to the regional contractors, who then enter into arrangements with the providers who practice in their region, and those providers who practice there must abide by those rules. The contractors only have authority over their areas, and cannot make or or enforce rules that would apply patients outside those regions, and may not determine benefits for patients nationwide. Patients are free to travel and seek care anywhere with the country, but their benefits remain the same since Medicare is a national plan. It is only the providers who are subject to the reimbursement rules set up by the individual jurisdictions.
 
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The LCD process is documented in the Medicare Program Integrity Manual, Chapter 13, which you can find here:

But again, I don't think you are going to find what you are looking for stated in those words, because it is a matter of jurisdiction, not of regulation - you have to understand from this that a Medicare contractor only has jurisdiction over payment for services rendered by providers who practice within that region.

The Social Security Act, as referenced in the manual above, defines an LCD as "a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary–or carrier–wide basis" So the LCD, by definition, is a 'local' determination of coverage, it only applies to claims for care that is rendered within that locality. Contractors cannot make determinations about care that is rendered outside of their own region just because a patient happens to have a residence in their region - they have no authority to do so. In other words, contractors have no say in how claims are processed outside of their own area.

Does that help some?
 
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We do work at an inpatient Rehab Facility, and we are in California. We routinely get patients here on vacation (well, pre-COVID), who were in a car accident or fell and broke a hip while on vacation. It doesn't matter whey THEY live; they are being treated here, and the facility and the provider both are contracted with Medicare where we are located, and that's who we bill for our services. I'm not even sure the patient's home contractor would know that we were billing our contractor (unless they have some sort of reciprocal agreement - frankly I've never thought about it).
 
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jamesbzn said:
But where is the rule that says this? I'm looking for the rule or Medicare Manual section, or whatever, that says this is how LCD policies are applied.
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Can you tell us the importance of this? Did you do a procedure that would be covered at the patient's home location but not at yours? Are you trying to appeal something? Sometimes, more information about the backstory might help.
 
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thomas7331 said:
The LCD process is documented in the Medicare Program Integrity Manual, Chapter 13, which you can find here:

But again, I don't think you are going to find what you are looking for stated in those words, because it is a matter of jurisdiction, not of regulation - you have to understand from this that a Medicare contractor only has jurisdiction over payment for services rendered by providers who practice within that region.

The Social Security Act, as referenced in the manual above, defines an LCD as "a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary–or carrier–wide basis" So the LCD, by definition, is a 'local' determination of coverage, it only applies to claims for care that is rendered within that locality. Contractors cannot make determinations about care that is rendered outside of their own region just because a patient happens to have a residence in their region - they have no authority to do so. In other words, contractors have no say in how claims are processed outside of their own area.

Does that help some?
Click to expand...

Yes, this is very helpful. But I need to find something in writing. Perhaps another way to approach this is to find the regs that talk about which MAC gets billed. Is there a Medicare manual or other regulation that says Medicare claims are sent to the MAC where service was provided versus where the patient resides? For example if patient lives in DC (Novitas) and has a procedure performed in VA (Palmetto), what is the regulation that says provider must send the Claim form to Palmetto? What if the Provider has offices in both DC and VA?
 
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This is most likely the information you want. I'm not 100% sure if it is spelled out black and white in an IOM somewhere, but these links specify that the provider bills the assigned MAC for their region. If the patient receives services that are billed to Palmetto and denied under an LCD, it can always be appealed and the QIC can be provided information that indicates other MACs cover the service as billed. The QIC can overturn the denial if it is based on an LCD, but really you are stuck on initial billing with the assigned MAC.
 
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