What is a “Local Coverage Determination” (LCD)?
Medicare contracts with private companies like Palmetto, Noridian, Novitas, etc. to administrate—process and pay claims in a specific region. Medicare Carriers and Fiscal Intermediaries (FIs) are private companies that Medicare contracts with to pay bills. More recently some FI’s have been replaced with the MAC (Medicare Administrative Contractor).
Just as commercial carriers have different coverage policies, one may cover a specific CPT code or drug, while others do not, so also the different carriers or intermediaries who contract with Medicare to administrate in certain region or regions. Carriers, FIs, and MACs make coverage decisions in the areas under their jurisdiction about what items or services are reasonable and necessary.
If there is an LCD for the types of services that you render and you do not use your LCD, you will very likely receive denials. I often hear from providers who just do not understand these “mysterious” Medicare denials they are getting. A quick check will usually prove that the LCD was not abided by and that was the reason for the denial.
Where can I find the LCD for my area?
The link to the Medicare LCD index by state can be found here: http://tinyurl.com/n5snzq