If a national and local Medicare coverage policy is published, Medicare physicians are expected to be aware of it, even if you have limited contact with patients. Ignorance is no excuse: Medicare will reject claims that don’t adhere to the policies.
You can find national policies in coverage provisions of interpretive manuals from the Centers for Medicare & Medicaid Services (CMS) and in the CMS Medicare Coverage Database of National Coverage Determinations (NCDs).
In the absence of national coverage policy, a Local Coverage Determination (LCD) indicates which items/services a local Medicare contractor — i.e., for Texas, TrailBlazer Health Enterprises — considers reasonable, medically necessary, and appropriate. CMS allows each Medicare contractor to develop LCDs pertinent to its areas of jurisdiction.
Each LCD contains the following:
- Indications and limitations of coverage and/or medical necessity,
- ICD-9-CM codes that support medical necessity,
- Documentation requirements,
- Utilization/frequency guidelines, and
- Attached coding article.
You can easily search LCDs based on procedure code or keyword using TrailBlazer’s LCD search tool. If an LCD exists for a service you are providing and the patient’s condition does not meet the medical necessity guidelines outlined in the LCD, an Advance Beneficiary Notice of Non-Coverage (PDF) (Form CMS-R-131) may be required.
If there is a question regarding the number of times a service has been furnished to the patient within a specific period, you should clarify this information with either the patient or the physician who ordered the tests.
Published Nov. 17, 2011
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