Master Core Curriculum

1. Master Core Curriculum Part A Intermediate Module 3 Medical Policy

2. Learning Outcomes At the end of the module, participants will be able to: • describe the purpose of Local Coverage Determinations (LCDs) • bill for services when LCDs apply • determine when to submit medical documentation with a claim, and be able to do so upon request • describe timeframes for submitting Additional Documentation Request (ADR)

3. Medicare Policies • Medicare policies appear in the form of: • Regulations • National Coverage Determinations (NCDs) • Coverage provisions of interpretive manuals, and • Local Coverage Determinations (LCDs)

4. The Medicare Medical Review (MR) Program • Statutory authority for the MR program is found in various sections of the Social Security Act (the Act) • Regulatory authority for the intermediary MR program rests in 42 CFR 421.100

5. NCDs • Describe circumstances for coverage of a specific medical service, procedure or device • Generally outline the conditions for coverage (or non-coverage) of a service under the Act • Issued as a program instruction and are binding on all Medicare contractors • Binding on Administrative Law Judges (ALJ) during the claim appeal process

6. NCDs • NCDs should not be confused with • “National Coverage Requests” or • “Coverage Decision Memoranda” • Coverage provisions in interpretive manuals

7. LCDs • An LCD represents a decision by a Fiscal Intermediary (FI) whether to cover a particular service • The creation of this term replaces the term Local Medical Review Policy (LMRP) • There is a content difference between LMRPs and LCDs • Final rule for LCDs was published November 11, 2003

8. Conversion of LMRPs to LCDs • Benefit category, statutory exclusion and coding provision information must be removed • All LMRPs must be converted to LCDs no later than December 2005 • Any non-reasonable and necessary language must be communicated via other means

9. LCD Development • Identify a service that is never covered under certain circumstances • Establish automated review • Absence of an NCD • Absence of coverage provision in CMS interpretive manuals • “Least Costly Alternative” (LCA)

10. LCD Development • Contractors have the option to develop LCDs when any of the following occur: • Validated widespread problem • Needed to assure beneficiary access to care • Uniformity across Contractors’ jurisdictions • Frequent denials – (issued or anticipated)

11. Purpose of LCDs • Ensure appropriate utilization of Medicare benefits • Facilitate decision making by both contractor and provider staff • Educate beneficiaries, care givers and providers on what Medicare DOES cover • Assures beneficiaries access to care

12. What May Appear in an LCD • Codes describing what is covered and not covered • Lists of HCPCS • Lists of ICD-9-CM codes

13. Application of LCDs in Billing • When billing claims to Medicare providers should: • Review LCDs for reasonable and necessary provisions • Ensure use of valid HCPCS and ICD-9-CM codes • Ensure codes submitted apply to year service is performed

14. MR of Claims • Perform claims review based upon Medicare policies • Review may be provider specific or service specific • Requirements for MR of claims are: • Benefit category review, • Statutory exclusion review, • Reasonable and necessary review, and/or • Coding review

15. Initiating a Prepay or Post-pay Medical Review • Contractors must notify providers of the following: • Provider has been selected for review • Specific reason for review • If review will occur prepay or post-pay • If post-pay, the list of claims requiring medical records

16. ADR • It is issued during the medical review process • Additional Documentation Request (ADR) must: • Be solicited from billing provider • Notify provider they have 30 days to respond • Indicate the specific pieces of documentation needed

17. Chapter Review Slide • Who is responsible for creating LCDs? • Why are LCDs developed? • What is the purpose of an LCD?

18. NCD National Coverage Determination LCD Local Coverage Determination LMRP Local Medical Review Policy MR Medical Review ALJ Administrative Law Judge FI Fiscal Intermediary SSA or the Act Social Security Act HCPCS Health Care Common Procedure Coding System Acronyms

19. ICD-9-CM International Classification of Diseases 9th Revision Clinical Modification CPT Current Procedural Terminology CFR Code of Federal Regulations PSC Program Safeguard Contractor ADR Additional Documentation Request IOM Internet Only Manual (IOM) FISS Fiscal Intermediary Standard System Acronyms

20. References • CMS IOMs • IOM 100-8, Medicare Program Integrity Manual, Chapter 13, Section 13.1 • IOM 100-8, Medicare Program Integrity Manual, Chapter 1, Section 1.2 • IOM 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.4