Way to avoid Appeal

 Become familiar with Local Coverage Determinations (LCD).

    * An LCD is a decision by a Medicare contractor whether to cover a particular item or service.  LCDs contain “reasonable and necessary” information and are administrative and educational tools to assist you in submitting correct claims for payment.
    * LCDs are located in the Medical Policy Center on the Highmark Medicare Services website.

 Become familiar with National Coverage Determinations (NCD).

    * The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on §1862(a)(1) of the Act (the “not reasonable and necessary” exclusion) unless otherwise specifically noted.
    * NCDs are located on the CMS website.

 Append modifiers to services when appropriate. Failure to append a modifier when appropriate will result in a denial.

    * Modifiers provide the means to indicate a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.
    * Appropriate modifier scenarios include:
          o  a service or procedure has both a professional (26) and technical (TC) component
          o a service or procedure was performed by more than one physician (77)
          o a service or procedure has been increased (22) or reduced (52)
          o only part of a service was performed (54 or 55)
          o an adjunctive service was performed (59)
          o a bilateral procedure was performed (50)
          o a service or procedure was provided more than once unusual events occurred (76)

Q: What is the difference between LCDs and NCDs?

A. Local coverage determinations (LCDs) for a specific jurisdiction are developed by the Medicare Administrative Contractor (MAC) assigned to that jurisdiction. First Coast Service Options Inc. is the MAC for Florida, Puerto Rico, and the U.S. Virgin Islands. Although the majority of coverage determinations are local, in certain cases, Medicare may develop a national coverage determination (NCD) that is applicable to all jurisdictions.

Q: Where can I find LCDs on First Coast Service Options Inc.’s Medicare provider website?
A. The Centers for Medicare & Medicaid Services’ (CMS) Medicare coverage database (MCD) holds the official versions of local coverage determinations (LCD). First Coast’s LCD lookup provides an easy way to access the MCD.

The quickest way is to use the MCD quick find. You will need the LCD ID (“L” number to use the quick find feature; if you do not have the LCD ID but you do have the procedure code, you can use First Coast’s fee schedule lookup to find an LCD if one exists for that service. Complete the fee lookup form and if an LCD exists a link to it will be displayed beneath the fee results.

Q: What is the fastest way to find a list of active LCDs?

A. The Active, Future, and Retired LCDs page includes convenient links to First Coast Service Options Inc.’s LCDs published on the CMS site. We’ve done the hard work for you — just select the link for your location and line of business. Once you arrive on the CMS site, you have several options to change the number of LCDs shown per page as well as how the list is sorted to facilitate your search. You can also choose links to view retired and future effective LCDs. For more information, please review the Finding First Coast LCDs and related coverage information — how-to guide.

Q: Can I search for LCDs by diagnosis code?

A. Yes, instead of going to an outside website, providers can locate LCDs by searching procedure codes, keywords, or International Classification of Diseases 10th revision codes (ICD-10s) using First Coast’s own website search bar, located at the top of every page. All of the LCD data is on the First Coast website, making it simple to find the LCD providers are researching.
Simply enter a procedure code, keyword, or ICD-10 code into the website search bar and search “LCDs only” to find the matching results. This search function replaces the multiple steps currently required by other methods, and lets providers locate the corresponding LCDs by using First Coast’s own LCD data.

In addition, you can search for LCDs by diagnosis code on the CMS website. The Medicare coverage database external link allows you to search for LCDs in a variety of ways including keywords, “L number,” CPT/HCPCS procedure codes, and ICD-10 diagnosis codes. Search the Medicare coverage database external link. For more information, please review the Finding First Coast LCDs and related coverage information — how-to guide.

Find out about changing LCDs FAQ
Q: How can I “keep up” with changing medical coverage policies impacting my area?

A. The best way to stay informed is to subscribe to eNews, First Coast’s electronic mailing service. You’ll receive regular and special email notifications advising you of changes to the Medicare program. You may subscribe to as many lists as you wish including those exclusively focused on news related to LCDs. Subscribe to eNews.

LCD status and draft comments FAQ
Q: How do I find out the status of an LCD? How do I submit comments on draft LCDs?

A. You’ll find information regarding the status, comment periods, and release dates of draft LCDs on the Draft LCDs page. You can also learn how to submit comments on LCDs with this helpful article — Draft LCD review/comment guidelines.

Q: Where can I find more LCD resources?
A. You’ll find the latest LCD news and information on the Medical Coverage pages (Part A and Part B).