Nobody likes being rejected. Whether it’s for a date with that attractive barista at your favorite coffee shop, a loan to buy a swanky new car, or even just for payment of your office’s claims, you want to hear yes, yes, and more yes! So what’s with all these rejections for non-covered services you keep seeing? Well, maybe they are because of LCDs. No, not liquid crystal displays…we’re talking Local Coverage Determinations, and you should get to know them!
Since Medicare will only cover services that are “reasonable and necessary,” policies called Coverage Determinations are in place to decide whether or not a procedure or service meets these requirements. These policies are broken into two groups: National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). As you probably guessed, NCDs are the same nationwide while LCDs vary depending on the region where the services are provided. The US is broken into several regions controlled by Medicare Administrative Contractors (MACs) who handle patients, claims, and providers for their local area. These MACs are also in charge of making LCDs when NCDs are not available. When the MAC reviews a claim, if it finds that the services billed do not meet its LCD requirements, payment will be denied. This is when end up with EOBs stating things like “services deemed not a ‘medical necessity’” and “decision based on an LCD.”
So, now that you have the skinny on LCDs, how do you prevent these rejections? Familiarize yourself with your area’s LCDs, of course! The best way to do this is to check out the LCD index on the official CMS website. A wise approach would be to look up the most common codes that are billed out by your office and make sure you are meeting the requirements to be paid for these services. As new procedures and codes are added to your office’s repertoire, look them up BEFORE performing or billing for them to be sure you will be able to be paid.
If your office and billing staff get into the habit of checking your local index before billing, you may still have issues (we have to keep things interesting, right?) but LCD rejections won’t be one!
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