These are developed and published by CMS and apply to all states. NCDs are national policy granting, limiting or excluding Medicare coverage for a specific medical item or service. The Social Security Act, Sections 1869(f)(2)(B) and 1862(l)(5)(D) define LCDs and provide information on the process.
The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual. Proposed LCD document IDs begin with the letters "DL" (e.g., DL12345). LCD document IDs begin with the letter "L" (e.g., L12345).
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LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements.īefore an LCD becomes final, the MAC publishes Proposed LCDs, which include a public comment period. LCDs are specific to an item or service (procedure) and they define the specific diagnosis (illness or injury) for which the item or service is covered. (e.g., when an item or service is new) or when there is a need to further define an NCD for the specific region. MACs develop an LCD when there is no national coverage determination (NCD) MACs are Medicare contractors that develop LCDs and process Medicare claims. Draft articles have document IDs that begin with "DA" (e.g., DA12345).Ī Local Coverage Determination (LCD) is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular serviceĪnd therefore covered by Medicare within the specific jurisdiction that the MAC oversees. A Draft article will eventually be replaced by a Billing and Coding article once the Proposed LCD is released to a final LCD.Īrticles are often related to an LCD, and the relationship can be seen in the "Associated Documents" section of the Article or the LCD.Īrticle document IDs begin with the letter "A" (e.g., A12345). Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage" and the MAC will make no payment for the drug.ĭraft articles are articles written in support of a Proposed LCD. For purpose of this exclusion, "the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug. The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient.ĬMS has defined "not usually self-administered" according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a The Medicare program provides limited benefits for outpatient prescription drugs. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period.
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The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered. MACs are Medicare contractors that develop LCDs and Articles along with processing of Medicare claims.īilling and Coding articles provide guidance for the related Local Coverage Determination (LCD)Īnd assist providers in submitting correct claims for payment.īilling and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. Articles often contain coding or other guidelines that complement a Local Coverage Determination (LCD).
Local coverage Articles are a type of educational document published by the Medicare Administrative Contractors (MACs).
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