New coding professionals may think that being well-versed in the ICD-9-CM Official Guidelines for Coding and Reporting, Coding Clinic for ICD-9-CM, and CPT™ Assistant references are enough for accurate and consistent coding. However, it’s important that every coder become familiar with coverage policies and how they affect coding in each particular locale. This article will provide an overview of coverage determination policies from a national (i.e., Medicare) standpoint, as well as some of those that are designated as local coverage policies.
Medicare, along with other payers, requires that services provided to beneficiaries be considered reasonable and necessary. To ensure the necessity of certain services, coverage policies are created that provide certain clinical requirements, ICD-9-CM diagnosis codes and in some cases, ICD-9-CM or CPT procedure codes. The service is designated as meeting coverage criteria if the reported codes match those contained in the coverage policy and other clinical and/or frequency requirements are met. It is vitally important that coders understand they must continue to follow appropriate coding and ethical guidelines and assign the appropriate codes that most closely match the medical record documentation and not assign codes based upon those included in any coverage policy document.
Section 522 of the Benefits Improvement Protection Act (BIPA) defines a Local Coverage Determination (LCD) as a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis. These determinations are made in accordance with Section 1862(a)(1)(A) of the Social Security Act and act as determinations as to whether the service or item is reasonable and necessary. The vast majority of coverage policies is local in nature and developed by clinicians at the FI, carrier or Medicare Administrative Contractor (MAC) offices. In some cases, the Centers for Medicare and Medicaid Services (CMS) releases National Coverage Determination (NCD) policies that are applied on a national basis for all Medicare beneficiaries.
It is essential that coding professionals be able to access the online resources related to LCD and NCD policies; they are in constant flux and are constantly updated. While there are several commercially available products currently in the marketplace that apply LCD and NCD policies to coded claims data, coders should become familiar with the CMS Web site that provides an index of LCD and NCD policies, along with links to respective policies. This CMS group of coverage policy determinations is known as the Medicare Coverage Database (MCD) and can be found at http://www.cms.hhs.gov/CoverageGenInfo/.
From this site, the user may search for specific policies based on site of service, type of service, keyword, ICD-9-CM or CPT code and whether or not an LCD (based upon specific state in the country), NCD or both should be queried. The database also includes several searchable indexes, including an archive with LCD policies that have been retired within the past 2 years. Typically, an LCD will consist of two documents, one describing the LCD policy itself, using only reasonable and necessary language, and an LCD article, which may provide more information concerning the LCD, along with online links to the LCD. The MCD site also allows downloads of all current NCDs, LCDs and LCD articles.
Table 1 is an example of a portion of an NCD for coverage related to a Bone Mass Measurement (BMM) examination:
CMS released a Medical Learning Matters article related to BMMs: http://cms.hhs.gov/MLNMattersArticles/downloads/MM5521.pdf.
The original LCD may be found in the Medicare Coverage Database:
After reading the LCD, it’s clear that although the policy does contain code related information, much of the coverage requirements relate to clinical and frequency information. While this is outside the typical purview of most clinical coders, it is important to understand how the coding piece fits into the overall coverage policy. Coders who work in physician offices and clinics where these services are ordered, should ensure the providers have the detailed information and are clear about coverage requirements before the service is ordered.
As a part of the health care team that is committed to accuracy, consistency and compliance, the coding professional should ensure codes are assigned based on the documentation included in the medical record, and not based upon what is listed in an LCD or NCD, just to get the claim paid. More importantly, codes should never be revised after a claim has been suspended or denied, based only on inclusion in the coverage policy; codes must always match the documentation in the medical record. Proactive use and understanding of coverage policy information can help to avoid protracted billing discrepancies and denials down the road. The MCD is a very powerful tool that can provide a wealth of information in an easy-to-use format, with multiple search functions.
After becoming familiar with the CMS MCD Web site, test yourself with the following quiz:
1. The policies included in the MCD apply to the following patient population:
a. Medicare and Blue Cross only
b. Medicare only
c. Medicare and Medicaid only
d. All payers
2. The policies included in the MCD apply to the following service settings:
a. Physician office/clinic only
b. Hospital only
c. Physician office/clinic and hospital only
d. All sites of service where Medicare beneficiaries may receive services
3. The best use of the LCDs and NCDs is/are:
a. As a check list or “cheat sheet” for coding, so the claim may be processed and paid quickly.
b. Ensuring that the physician or other provider of services is aware of the coverage criteria before ordering the service.
c. Answering questions related to suspended or denied claims related to coding or frequency of services provided.
d. To determinewhich services to discontinue.
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com).
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1. b. Medicare only. Although some other payers may follow the policies, they are not required by law to follow Medicare coverage policies.
2. d. All sites of services. Some services may be deemed safe only when provided in a particular setting, but there are coverage policies for different types of services that may be provided in a variety of settings, including SNF and home health.
3. b and c only. The LCD and NCD information should not be used in the coding process after a service has been provided. They should be used proactively so providers understand coverage criteria before the service is ordered. The policies may also clarify billing issues related to suspended or denied claims, but should not be interpreted as punitive or indicative of services that should be discontinued.