DME MACs LCD Format Change - JA DME

Posted January 5, 2017

The DME MACs will be revising the DOCUMENTATION REQUIREMENTS section of all Local Coverage Determinations (LCDs) during our CMS-required annual LCD review. The LCD updates will be published in early 2017.

Historically, our LCDs focused on criteria necessary to determine that an item was reasonable and necessary. The DOCUMENTATION REQUIREMENTS section provided information related to the documentation of key policy-related payment rules, and suppliers were referred to the DME MACs Supplier Manuals for detailed discussion of documentation requirements associated with each payment rule.

Medicare contractor audits, including CERT audits, have demonstrated numerous errors associated with incomplete or missing documentation. In response to these audit findings, starting in 2011, the DME MACs expanded the DOCUMENTATION REQUIREMENTS sections to provide detailed information on each key payment rule. These documentation requirements were compiled from Statutes, Code of Federal Regulations, CMS manuals, supplier manuals, and DME MAC publications. The goal was to create a standardized set of requirements to assist DMEPOS suppliers in understanding the information necessary to justify payment, and lower the improper payment rate.

Over time, the administrative burden of maintaining these policies has dramatically increased. Even a minor change necessitates the updating of over 50 individual LCDs and their LCD related Policy Articles, with attendant risks of introducing clerical errors.

Thus, in 2017, we will be reverting back to the previous LCD format that existed prior to 2011, and general documentation requirements that have appeared within individual policies (LCDs) will be removed from all DME MAC LCDs.  The general documentation requirements will thereafter be located in a separate Standard Documentation Requirements LCD related Policy Article in the Medicare Database, which will be linked to all DME MAC LCDs.

In addition to the general documentation requirements, LCDs often contain documentation requirements that are unique to that specific policy. These requirements are termed "POLICY SPECIFIC DOCUMENTATION REQUIREMENTS". Historically, these requirements have appeared within the individual LCD DOCUMENTATION REQUIREMENTS section. Such information will be removed from all LCDs and will be moved to the LCD related Policy Article in the Medicare Database, which is currently linked to the applicable LCD.

It is important that suppliers review the LCD, the LCD related Policy Article, and the LCD related Standard Documentation Requirements Article, to ensure that they have all of the relevant information necessary and applicable to the item(s) provided.

Suppliers are reminded that these changes in the LCD format do not add any new requirements, nor remove any existing Medicare documentation requirements. In the event of a claim review (audit), the LCD format change does not obviate a supplier's obligation to provide sufficient documentation to demonstrate compliance with Medicare payment rules.