National Coverage Determination (NCD)
Medicare National Coverage Determinations. The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. The NCD’s are also part of the Internet Only Manual (IOM).
Reference from CFR that these must be followed by Administrative Law Judge (ALJ)
List the CMS website  in which they can be found
How we utilize these
Specific NCD’s relate to DME supplies or services. An alphabetical list of services that may or may not be covered by the NCD’s can be found at the following address :
http://www.cms.gov/mcd/index_list.asp?list_type=ncd
- The most common NCD used for Durable Medical Equipment (DME) is NCD 280.1. The term DME is defined as equipment which:
- Can withstand repeated use; i.e., could normally be rented and used by successive patients;
- Is primarily and customarily used to serve a medical purpose;
- Generally is not useful to a person in the absence of illness or injury; and,
- Is appropriate for use in a patient’s home.
Policy Articles
What are these?
Local policies consist of two separate, though usually closely related, documents: the LCD and the policy article. The LCD will contain only the reasonable and necessary language. Any non-reasonable and necessary language a Medicare contractor wishes to communicate to providers is done through the policy article.
How can they be utilized?
At the end of each LCD, there is a link to the related policy article and at the end of each policy article there is a link related to the LCD. |
Local Coverage Determination (LCD)
What are these?
Section 522 of the Benefits Improvement and Protection Act (BIPA) defines a Local Coverage Determination (LCD) as a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary). FIs, Carriers, Program Safeguard Contractors (PSC), and Medicare Administrative Contractors (MAC) are Medicare contractors that develop and/or adopt LCDs. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual.
How can they be utilized?
http://www.cms.gov/mcd/
Where can we find retired/superseded LCD’s?
Retired and Future LCD’s can also be found on CMS’ website. Please use the following links: Retired Future
How are they formatted (i.e. what are the headers in the LCD’s)?
Contractor Information
- Contractor Name
- Contractor Number
- Contractor Type
LCD Information
- LCD ID Number
- LCD Title
- Contractor’s Determination Number
- Copyright Statement
- Centers for Medicare & Medicaid Services (CMS) National Coverage Policy (pertaining to the LCD)
- Primary Geographic Jurisdiction
- Oversight Region
- Original Determination Effective Date
- Original Determination Ending Date
- Revision Effective Date
- Revision Ending Date
- Indications and Limitations of Coverage and/or Medical Necessity
Coding Information
- Bill Type Codes
- Revenue Codes
- CPT/HCPCS Codes
- Modifiers
- ICD-9/Diagnoses Codes that Support Medical Necessity
- ICD-9/Diagnoses Codes that Do Not Support Medical Necessity
General Information
- Documentation Requirements
- Appendices
- Utilization Guidelines
- Sources of Information and Basis for Decision
- Advisory Committee Meeting Notes
- Start Date of Comment Period
- End Date of Comment Period
- Start Date of Notice Period
- Revision History Number
- Revision Effective Date(s)
- Reason for Change
- Last Reviewed On Date
- Related Documents (including Policy Article link).
- LCD Attachments
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