Clinical documentation: Look to LCDs for guidance

Q. How do I know what Medicare wants in the documentation?
Wednesday, May 28, 2014

A. It seems like what they want and expect changes on a regular basis; however, most of the products you bill for have a local coverage determination (LCD). In that LCD is a section called “Coverage Indications, Limitations, and/or Medical Necessity.” This is essentially what Medicare expects to see in the clinical documentation. There are generally criteria listed that essentially says under these circumstances, Medicare will pay for this equipment. The clinical documentation must prove how the patient qualifies based on this section of the LCD. 

Years ago, clinicians at Medicare were allowed to use their clinical judgment in auditing claims. Now, they are simply looking to see how the criteria are specifically and precisely addressed without any clinical judgment.

Some equipment may not have a LCD and that certainly makes things more difficult. If it is a covered item, there is generally a national coverage determination that would provide some guidance or articles from the contractors. Otherwise, you must still document the need for the item and what is necessary. If there are other products or treatments available, particularly if they are less expensive, you will want the documentation to address how it was ruled out.

Educate physicians as best you can on the criteria, and if they have not done a good job showing how the patient qualifies, then the patient must be told that they can be held liable and a properly executed advanced beneficiary notice obtained. Otherwise, you are assuming that liability. The beneficiaries play an important role in the process of assuring their physician documents accordingly or deciding to pay themselves.

Wayne van Halem is president of The van Halem Group. Reach him at 404-343-1815 or