Coding and Billing

Coding & Billing: Making Medicare National & Local Carrier Determinations

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

April 4, 2018

If you want to know the rules, as well as what is covered and what is not covered by Medicare, then you must know about National Coverage Determinations and Local Coverage Determinations.

The Medicare web site says, “Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS’ own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).”

The place to go to find the NCDs and LCDs is the Medicare Coverage Database (MCD). This site contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local articles and proposed NCD decisions.

There are several ways to use the site. You can do a Quick Search using a variety of criteria such as keyword, diagnosis/procedure and date. You can do an Advanced Search. Indexes contain pre-defined lists of NCDs and LCDs. You can also explore the Reports section. Downloads permits downloading complete sets of NCDs and LCDs.

Using the Quick Search section you can search by ID or by Document Type. To give an example of the information you can obtain, we did a Quick Search for visual fields for Ohio. You can see from the image how easily we set up the search.

Clicking on Search By Type returned a web page that looked like this:

There are no NCDs for visual fields, but there is one article and two LCDs.

The article explained the criteria for each visual field CPT code including where you can bill the global (technical + professional) services, where the technical services can be billed and where the professional services can be billed.

 

 

 

 

 

 

 

 

The following additional information was provided for visual fields:

Coding Guidelines
• Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

• For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

• A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

• The diagnosis code(s) must best describe the patient’s condition for which the service was performed.

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines

The Medicare Learning Network provides a helpful document titled “How to Use the Medicare Coverage Database.” Page 3 of this booklet gives the reason that Medicare providers must understand this material, “CMS expects health care providers to know Medicare coverage requirements so they can anticipate payment denial. If a provider does not give the beneficiary proper written advance notice that Medicare will likely deny the service or item, the provider is financially liable.”

Our job is not just to provide care to patients, but we must also know the rules. Use the Medicare Coverage Database to look up the rules for all the procedures that you use to bill Medicare.

 

References
i. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/index.html
ii. https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
iii. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareCvrgeDatabase_ICN901346.pdf

 

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