LCD Retirement Clarification

Noridian periodically announces the retirement of Local Coverage Determinations (LCDs) in our publications. Medicare instructions relating to LCDs are found in the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13. A contractor will keep in place policies where there is evidence that there remain significant problems with performance, billing and/or coding of a service.

NOTE: Provider offices remain responsible for correct performance, coding, billing, and medical necessity under Medicare. This responsibility for correct claims submission is unchanged whether or not there is an LCD in place. 

Why are LCDs Retired?

LCDs are retired due to lack of evidence of current problems, or in some cases because the material is addressed by a National Coverage Determination (NCD), a coverage provision in a CMS interpretative manual or an article. Most LCDs are not retired because they are incorrect. The guidance in the retired LCD may be helpful in assessing medical necessity. Where providers have adjusted their billing and coding practices to correspond to the guidance in LCDs, they will want to be very careful in departing from these practices just because the LCD is retired.

Reviews Will Continue to be Conducted

Post-pay review will continue not only as before, but also with the addition of the Recovery Auditors (RAs). Payment for a service does not mean the service was medically necessary and/or correctly billed. The service may therefore be subject to recoupment even several years later.

Medical Necessity and ABNs

Finally, whether or not a service is addressed in an LCD, if the provider believes the service is not reasonable and necessary under Medicare guidelines, then a modifier (GA or GZ) must be appended, and an Advance Beneficiary Notice of Noncoverage (ABN) may be obtained to avoid provider liability. As always, documentation must be present in the medical record to support the performance of billed services as well as the medical necessity.

 

Last Updated Tue, 14 Jan 2020 14:42:17 +0000