The MCD is used by Medicare Administrative Contractors (MACs), providers and other healthcare industry professional to determine whether procedures or services is reasonable and necessary for the diagnosis or treatment of an illness or injury.
MCD also includes all Medicare National Coverage Determinations (NCDs), National Coverage Analyses (NCAs), Local Coverage Determinations (LCDs), and local articles, Coding Analyses for Labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MedCAC) proceedings, and Medicare coverage guidance documents.
National Coverage Determinations (NCDs) develops by CMS on an ongoing basis, while Local Coverage Determinations (LCDs) is created by Medicare Administrative Contractors.
What is the importance of NCD and LCD?
NCDs and LCDs plays an important role in linking ICD-9-CM or ICD-10-CM diagnoses codes with procedures or services. CMS expects healthcare providers to know Medicare coverage requirments so they can anticipate payment denial. If the provider does not give the beneficiary proper written advance notice that Medicare will likely deny the service or item, the provider is financially liable. However, if the provider gives the beneficiary proper written advance notice that Medicare will likely deny payment for service or item and indicates this action on the claim (like appending -GA modifier to a procedure code), the beneficiary may be held liable.
Is it MCD always updated?
CMS updates the national coverage information in the MCD in real time, except the national coverage download, which is updated weekly and local coverage information, which is updated on a weekly basis, usually on Thursday. In addition, it is advisable to subscribe to Medicare Administrative Contractor (MAC) via electronic mailing list in order to be notified of new or changing LCD.
An Advance Beneficiary Notice (ABN) is a waiver required by Medicare for all outpatient and providers office procedures/services that are not covered by the Medicare program. Patients sign the waiver to indicate that they understand the procedure or service is not covered by Medicare and they will be financially responsible in paying the provider for the procedure performed.
Alert: If the waiver is not signed before the procedure/service is provided and Medicare denies coverage, the perception is that the provider is providing free services to Medicare patients - this is considered fraud by the Office of Inspector General for CMS!
Is it MCD always updated?
CMS updates the national coverage information in the MCD in real time, except the national coverage download, which is updated weekly and local coverage information, which is updated on a weekly basis, usually on Thursday. In addition, it is advisable to subscribe to Medicare Administrative Contractor (MAC) via electronic mailing list in order to be notified of new or changing LCD.
Alert: If the waiver is not signed before the procedure/service is provided and Medicare denies coverage, the perception is that the provider is providing free services to Medicare patients - this is considered fraud by the Office of Inspector General for CMS!
ABN form should not be given to someone who is in medical emergency, confused, legally incompetent, or under great duress. It cannot be signed after a patient has received the service and must specifically state what service or procedure is being waived.
As mentioned above, to determine services require an ABN, refer to the NCDs and the LCDs from the insurance carrier. An office must have an office policy in place if a patient refuse to sign an ABN. When sending a claim append modifier -GA (waiver of liability on file) to specified code indicating a patient signed a waiver. The Medicare carrier then informs the patient that he or she is responsible for the fee. Keep the waiver on patient financial document separately not with patient's health record.
For Noncovered Services
Do not be confused and give a patient an ABN when service is never covered by Medicare, because this may always be billed to the patient. A different form called
Notice of Exclusion from Medicare Benefits (NEMB).
This form clearly states that the service is never covered by Medicare and the patient is responsible for payment. Although it is not mandatory for the patient to give NEMB for a never-covered service, but use of form makes it clear before the procedure is given that he or she must pay for the service rendered by the provider.
Sample Abstracting a Coding Case Scenario
The patient is seen in the emergency department (ED) physician performed a level 3 evaluation on a patient who was seen for a complains of severe abdominal pain, nausea and vomiting. An ultrasound revealed an enlarged gallbladder. A surgeon was called in, evaluated the patient (conducting a level 3 new patient E/M service), and performed a laparoscopic cholecystectomy, which releaved acute cholecystitis. The patient's stay was less than 24 hours.
Billed by the admitting physician
CPT Code Description ICD-9/10 Code Description 99283 ED Visit Level 3 789.03/R10.31- Abd. pain, RLQ
76705 Ultrasound, abdominal, 575.8/K82.8 - Hypertrophic gallbladder
real time with image docu.; 787.01/R11.2 - Nausea and vomiting
limited (eg,1 organ, quadrant)
Billed by the surgeon
CPT Code Description ICD-9/10 Code Description
47562 Laparoscopy, surgical;
cholecystectomy
Current Procedural Terminology (CPT®) copyright from American Medical Association.
CPT is a registered trademark of the American Medical Association.
Pub 100-3, 100.13 - Laproscopic Cholecystectomy
NCD for Laproscopic Cholecystectomy (100.13)
Laparoscopic cholecystectomy is a covered surgical procedure in which a diseased gall
bladder is removed through the use of instruments introduced via cannulae, with vision of
the operative field maintained by use of a high-resolution television camera-monitor
system (video laparoscope). For inpatient claims, report the diagnosis code for
laparoscopic cholecystectomy. For all other claims, report the appropriate CPT code 47562 for
laparoscopy, surgical; cholecystectomy, and the appropriate CPT code 49311 for
laparoscopy, surgical: cholecystectomy with cholangiography
