Local Coverage Determination (LCD)
A Local Coverage Determination (LCD) is a decision by a Medicare Administrative Contractor (MAC) whether to cover a particular service on a MAC-wide, basis. Codes describing what is covered and what is not covered can be part of the LCD. This includes, for example, lists of HCPCs codes that spell out which services the LCD applies to, lists of diagnoses codes for which the service is covered and even lists of diagnoses codes for which the service is not considered reasonable and necessary. Coding descriptions are included if they are integral to the discussion of medical necessity.
The LCD timelines relating to LCD development, reconsideration, revision, and review are provided on this webpage. CMS has determined and published applicable timelines, which may be viewed in the CMS Internet Only Manual (IOM), Medicare Program Integrity Manual, Publication 100-08, Chapter 13 .
There are four distinct stages involved in processing an LCD from draft to active status:
- Comment Period - Comment Period is a Minimum of 45 Days - Noridian considers all comments from the public, and the medical community. The comment period begins when the policy is distributed to medical providers, and organizations. Noridian responds to comments via comment/response notations within the LCD under the section Advisory Committee Meeting Notes.
- Comment Review Period, with Development of Responses - This timeframe begins after the 45 day Comment Period ends. During this period the Contractor Medical Directors (CMD) review all comments, develop responses, update the LCD, and prepare for the Notice Period.
- Notice Period - Once the LCD is amended in accordance with the responses to the comments, the LCD is posted to the CMS website in the Medicare Coverage Database (MCD) as a Final LCD, however; it is not yet active. Providers do have 45 days from the date of posting notice to implement billing changes and educate staff before the LCD implementation.
- Active Period (LCD is in Effect) - The actual LCD implementation date is the effective date and occurs on the 46th day from the first date of the Notice Period. Located in the body of the LCD under the, "Original Determination Effective Date," or "Revision Effective Date" depending on whether the LCD is new or revised.
Within 30 days of the LCD Reconsideration Administrator receiving the request, Noridian must determine whether the request is valid or invalid and must notify the requestor. If invalid Noridian will respond; in writing; to the requestor explaining why the request was not valid. If the request is valid, Noridian will make a final LCD reconsideration determination and notify the requestor of the decision within 90 days of the request receipt date.
Review and Revision
Noridian shall review and appropriately revise the affected LCD within 90 days of the publication of program instruction (e.g., Program Memorandum, manual change) containing:
- A new or revised National Coverage Determination (NCD)
- A new or revised coverage provision in an interpretive manual; or
- A change to national payment policy.
The MCD will notify contractors of each LCD that is affected by an update to a HCPCS code or diagnoses code. Noridian shall review and approve and/or appropriately revise affected LCDs within 120 days of the date of notification. If there are major changes, Noridian shall revise the effective date, revision number and revision history.
Noridian shall annually review and revise all LCDs to ensure they remain accurate and up-to-date at all times based upon the CMS NCDs, coverage provisions in interpretive manuals, national payment policies, and national coding policies.
Last Updated Dec 27, 2016