Nick Hopper, Director of Commercial Operations for Novus Healthcare Solutions. Today, we're going to discuss local coverage determinations or LCDs, criteria that is set by the payers in order to show coverage for a DME item that is prescribed at your practice. Objectives include identifying LCDs or local coverage determinations that affect your DME program. Determine what LCDs mean for your DME program and how they can help run your DME program as well from a coverage criteria standpoint. Next, we'll establish the difference between LCDs as well as NCDs or national coverage determinations that affect the country as a whole versus LCDs that can be more so specific to your location or region. Next, we'll develop strategies to adhere to LCD guidelines for your practice. These can help avoid denials, ensure medical criteria is met, as well as staying up to date. Lastly, we'll understand updates to LCDs and how to stay current on these updates as your practice has to adhere to. Our local coverage determinations or LCDs, these are decisions made by your Medicare Administrative Contractor or your MAC about whether a particular service or item is covered by Medicare within their jurisdiction as defined by your MAC, whether it's Noridian or CGS, and there's some subsidiaries underneath that. The LCDs will detail the coverage and criteria that goes along with limitations for a particular service, procedure, or device. This may be in relation, once again, to the extremity, to the HCPCS code, and then in relation to that, what criteria has to be met, whether from a criteria standpoint, from a medical standpoint, possibly HCPCS codes, along with diagnosis codes as well. Typically, there's a number of Typically, this is defined by extremity or a group of HCPCS codes defined by that extremity or body area, but can vary depending on that MAC's jurisdiction as well. Local coverage determinations, as they are established by that MAC, whether it's through Noridian or CGS, are posted and, according to the timelines below, are reviewed over a nine-month process. There is the ability over a 30-day into a 60-day process for public comments to be added by practices such as yourself, and at times, this does successfully either alter that LCD or, at times, this challenge that LCD as well. Very important to be within the LISTSERVs for your MAC, for your region as well, as these are presented, updated, and then put into existence as well. Using your DME program, an integral part of reviewing, staying up to date, as well as integrating or implementing any type of change for your DME program with the devices that you do distribute with these LCDs updates. LCDs do establish coverage criteria and define diagnosis codes for which a HCPCS code is payable. This also can include the medical documentation that has to be on file as well. The absence of an LCD does not mean non-coverage, just means that there hasn't been anything evidence-based or updated to show that coverage does have to occur, but there may be some criteria that is very basic still for coverage of that race if an LCD is not present. These can be revised as well as requested at any time from your MAC. With that, all of the dates of updates, submission, are always readily available on that LCD document that is available electronically within your MAC, whether within Meridian or CGS from your database. These policies will determine if an item is reasonable and necessary. It is key to stay up to date with these. Put it in a format that is available for your clinical staff to review to adjust maybe their dispensement criteria as well as when they are dictating the medical criteria for the brace that we are meeting LCD requirements as established by your MAC. For using LCDs in your DME program, do reference electronic versions of LCDs to ensure the appropriate version is being utilized based on the date of service when that brace was dispensed. Once again, these will be available within your MAC electronically online, whether it's Meridian or CGS. Review LCDs carefully as well as completely. Do not use them as a reference carefully as well as completely. At times, this will include HCPCS updates. Once again, the diagnosis criteria updates as well as any type of medical necessity that needs to be on file that may go along with the claim submission or possibly upon appeal of any type of denials. Providers, billing personnel, and others who may be responsible for filing claims in Medicare encourage you to be aware of all information contained within LCD. This will include the diagnosis code criteria, the HCPCS that are affected, as well as the medical criteria, as well as some of that evidence-based criteria that has helped generate this LCD for coverage of that brace or device. Do a review process and navigate the electronic portals of LCDs. Keep in mind your DME partners also are at the forefront of this communication as well, whether they are a manufacturer or vendor or a software supplier as well or all of the above. So, keep that in mind and utilize your right resources as these LCDs are generated or updated for your practice and program. Local coverage determinations have some subtle differences to national coverage determinations or NCDs. On the left, you can see LCDs are created by that local administrative contractor or MAC. It only applies to the jurisdiction with which your practice is within. So, there can be different LCDs across the nation depending on the MAC and jurisdiction that your practice is within. Can vary, can be updated separately as well, hence why staying up to date is very important. This is an issue when there's no NCD or national coverage determination or maybe that NCD is determined by that MAC not to be specific enough. Now, LCDs are very common. You'll see these often whether based off of a subset of HCPCS code, an extremity, body area, or a category of a DME item or device as well. So, very common, seen quite a bit. NCDs, once again, national coverage determinations are holistically generated and affect the nation. And this is generated by the Centers for Medicare and Medicaid Services. All Medicare beneficiaries in this aspect have the same coverage. Now, the NCDs can start to affect the private payers as they follow criteria as well. While these are less common than LCDs, you will see your private payers follow these national coverage determinations at a higher level. These are issued in situations such as new medical devices are within practices, conflicting local policies, or possibly disputes that have occurred as well. So, key to be informed of both of these, the Centers for Medicare and Medicaid Services can be accessed easily online to stay up to date with these along with the listservs that they have, along with, obviously, the LCDs that your MAC determined through Noridian or CGS, and then your jurisdiction subset as well to stay up to date. Staying current with LCDs is a key component for your DME program. One, use the Medicare coverage database that your practice has access to as a DME as well as Medicare provider that is credentialed. Download LCD data. This can be available whether it's through Noridian or CGS and your subset of jurisdiction that you're located within. That information is readily available for you by extremity underneath the DME coverage section as well. There also is the ability within your MAC, whether once again CGS or Noridian in the jurisdiction, to sign up for email updates. With that within your inbox on at least weekly update, updated standpoint, or whenever there is any type of updates to LCDs, these will be delivered to you to update your DME program, review, as well as can really help from a coverage criteria to education of your provider standpoint as well to meet criteria. Lastly, utilize your DME vendors, whether it's a manufacturer or vendor of your DME products or possibly a supplier of the DME software within your practice. A lot of DME softwares will include the LCDs as well as NCDs within the software to ensure that when you are dispensing a brace, you're meeting that criteria as well. In summary, knowledge of LCDs are a key component for coverage of DME items. This can help establish coverage, avoid denials, and really help the collections percentage as well as first pass yield for your practice. Staying current is key with those different databases that this information is readily available as a credentialed DME supplier. This can impact medical criteria and once again is an integral part of your DME program. One area to keep in mind is just adjusting your medical documentation as LCDs are either updated, developed, or even sometimes deleted. This does need to be implemented in practice and reviewed as these updates or implementations do occur.

Local Coverage Determinations

Durable Medical Equipment

Medicare Administrative Contractors

compliance

reimbursement