When a Medicare Administrative Contractor makes a ruling as to whether a service or item can be reimbursed, it is known as a local coverage determination (LCD). It is always based on medical necessity and is valid only in the contractor’s designated region. For example, if you are a healthcare provider based in New York, an administrative contractor called “National Government Services” determines your LCD, i.e., the conditions of payment for the services that you render. The CPT manual determines which procedure codes are always under a jurisdiction of LCD.
However, sometimes it is not a MAC, but the Centers for Medicare and Medicaid Services that make a decision on whether to cover a certain procedure or not. Such decisions are made on a national level, meaning that certain conditions must be met all around the USA in order for a specific procedure to be paid. Hence the name, National Coverage Determination (NCD). NCD covers the services that are not mentioned in a regional LCD.
Both NCDs and LCDs establish policies that are specific to an item or service. They also define the diagnosis codes for which the procedure is payable.
Are you sure that your current treatment patterns are compliant with NCD/LCD regulations?
At WCH Service Bureau, we strive to provide top-quality all-encompassing solutions to our clients. This includes an internal auditing service. Our team of certified coders and chart auditors can help you ensure that your practice is on the same page with the current guidelines. Contact us!