Ask the DMERC MDs

Thursday, June 30, 2005

Q. I cannot find the Coding Guidelines in the Local Coverage Determination. Some of the coverage criteria have been moved from the LCD to a Policy Article. What is going on here?
A. Medical policies have been changing over the past year. In the past Local Medical Review Policies (LMRPs) contained all coverage information, HCPCS codes, coding guidelines, and documentation requirements. In addition, statutory coverage requirements, National Coverage Determinations (NCDs), least costly medically appropriate alternative (downcoding) determinations, and utilization guidelines were all included in our traditional narrative format. This format was a useful approach to giving suppliers the information necessary to provide items to beneficiaries.
Several years ago, Congress passed the Benefits Improvement and Protection Act of 2000 (BIPA). BIPA defined the concept of Local Coverage Determinations (LCDs) to help identify those sections of medical policies that contain coverage criteria established by the contractors. Thus, Local Coverage Determinations and related Policy Articles came into being.
The principle element in the LCD is the "Indications and Limitations of Coverage and/or Medical Necessity" section. The "Indications" section contains only medical necessity criteria developed by the DMERC through the policy development process and any related NCD requirements. Statutory requirements are no longer included in this section. The "Documentation Requirements" and "HCPCS Code" sections remain and are unchanged. New sections include a "Revision History Explanation" section. This area contains a running summary of changes that have occurred from revision to revision.
The related Policy Article is a new document created to contain policy related information not appropriate for inclusion in the LCD. Statutory requirements are contained in the "Non-Medical Necessity Coverage and Payment Rules" section. In addition, coding instructions are in the "Coding Guidelines" section. The Policy Article also has a "Revision History Explanation" section for reference.
It is essential to understand that suppliers must be familiar with BOTH documents in order to have a complete understanding of all the relevant information needed for any policy. Using only the LCD or Policy Article may cause you to miss criteria information that may affect your claims adjudication.


If you have a question that's both timely and nationally relevant, e-mail your question to The medical directors are Paul Hughes, M.D. (Region A), Adrian Oleck, M.D. (Region B), Robert Hoover, M.D. (Region D) and Stacey Brennan, M.D. (Region C)