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Get the lowdown on LCDs

Rehab Regs, August 11, 2004

Here's a refresher on the policies essential to your reimbursement

If you wonder whether certain local and national Medicare policies apply to the services you provide and how to tell the difference between the two, here's how to keep the information straight.

There are two types of Medicare coverage policies:

But NCDs don't always exist for certain services, according to Lee Heinbaugh, consultant for PMG, LLC, long-term care consultants in Cleveland. "If there's a miscommunication or confusion among fiscal intermediaries (FIs), CMS might develop an NCD to be understood by all," says Heinbaugh.

LCDs can exist even if there is no NCD in place for a specific service. But if there is an NCD regarding a certain issue, the LCD can get more stringent, but not reinterpret the coverage decision.

Staff members at your facility should be using both the NCD and the LCD specific to the area they serve together to more fully understand what services are reimbursable, according to Dill.

Situations exist where the NCD and the LCD might contradict each other or create confusion regarding regulations. LCDs are supposed to be consistent with NCDs, but questions pop up from providers about the two, Dill says.

"CMS doesn't approve LCDs, but [it] can review them to make sure they don't conflict with NCDs," says Dill. She adds that providers can submit requests for changes to either set of guidelines by visiting either the CMS or individual Medicare contractor's Web site.

Likewise, CMS can issue an NCD change that can trigger an LCD change, so keep up with ongoing alterations to the policies. CMS releases changes as they occur and could average about 10 a month, according to Dill.

Keeping up on changes is especially important if your facility is having an increasing number of its claims denied. You might think you are billing as usual, and find that your revenue could be decreasing because a procedure code has been altered. From clinicians to billers, everyone should be at least aware of changes that affect the services they document and bill for.

"[Knowing about coverage changes] usually falls to the people in the business office, but if you're in a private practice, you don't have the luxury of a separate billing office," says Dill. "It's key that everyone is aware of their LCD."

You can comment on LCDs before they are issued if you feel a proposed policy is incorrect or unfairly restrictive. CMS requires that contractors make the process open to the public, issue a draft, and solicit input from the public before issuing the final policy.

It's the public's opportunity to comment on an LCD before it's put into final form, says Dill.

Heinbaugh also mentions that policies have renewal dates. So CMS or your FI could decide not to renew a policy that was either outdated or irrelevant and render it null and void.

Someone in your facility should try to develop a relationship with your local carrier or FI, Dill says. Your FI's Web site should list a contact person you can call for questions and clarifications.

Dill also suggests that once you've received an explanation from the FI representative, you may want to follow up the telephone conversation with a note. The note will not only give you something to refer to if the question comes up again, but it also ensures that you understood the explanation correctly.

"You don't want to overburden your therapy staff, but if it's a big enough issue, you should document the conversation," says Dill. "Developing a relationship with your carriers is always a good business practice."

Finally, sign up for any bulletins from your FI on provider education programs as well as CMS's Medicare program transmittal updates. "There's a tremendous amount of information out there," says Dill. "You must lose that fear of asking questions so that you can understand those policies that [affect] your practice. Lack of familiarity is usually not an accepted reason for not following LCDs."

Visit CMS's Web site www.cms.hhs.gov/mcd/search.asp for additional information on national and local coverage policies.

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