Last Modified: 10/21/2024
Location: FL, PR, USVI
Business: Part A, Part B
What if you cannot locate any information on a specific item or service? The absence of an LCD does not mean non-coverage. It means that currently, we have not identified the service as requiring a local policy. Medicare relies on providers to report services appropriately, so payment is made only for services that are reasonable and necessary. In the absence of an LCD, NCD, billing and coding article, CMS manual instruction, NCCI, or MUE;
reasonable and necessary guidelines still apply.
LCDs are developed to convey under what circumstances an item/service is considered to be reasonable and necessary. We will consider reasonable and necessary services for payment in the absence of an LCD, billing and coding article, NCD, or CMS manual instruction limiting coverage. All LCDs must be based on
evidence.
Please review our
LCD development process and
LCD development process flowchart.
Components of an LCD
There are many components that comprise an LCD: contractor information, LCD information, CMS national coverage policy, coverage guidance to include covered indications and limitations, general information, summary of evidence, analysis of evidence, revision history information, and associated documents.
Helpful hints for LCDs
• It is recommended to reference the electronic version of LCDs (not printed versions) to ensure the appropriate version is being utilized based on date of service.
• Review LCDs carefully and completely.
• Providers, billing personnel, and others who may be responsible for filing claims to Medicare are encouraged to be aware of all information contained within an LCD.
LCD revisions
Requesting a new LCD
The new LCD request process is a mechanism that provides an opportunity for interested parties within our jurisdiction to request a new LCD. An LCD is not written to convey an item/service is covered but can set coverage limitations or establish non-coverage of an item/service. Specific requirements must be met when requesting a new LCD. Please review our
new LCD request process and
request a new LCD process flowchart.
Articles convey billing and coding information, guidelines, and communicate any non-reasonable and necessary language. They may be related to an LCD or may be standalone documents to provide billing and coding guidance in relation to CMS’ Medicare guidelines. Effective December 14, 2023, our billing and coding articles will include a yellow banner that will indicate if the Article is an LCD reference article or if it is a standalone article not related to an LCD.
Components of a billing and coding article
The components of a billing and coding article may include general information, coding guidance, documentation requirements, utilization parameters, modifier information, ICD-10 diagnosis codes, CPT and HCPCS codes, revenue codes, and bill types. A link to the associated LCD, if any, will appear in the associated document portion of the billing and coding article.
Helpful hints for billing and coding articles
Many CPT/HCPCS procedure and/or ICD-10 diagnosis codes may be listed within a billing and coding article. For better results in searching for a specific procedure or diagnosis code within a billing and coding article:
• Use CTRL+F to search within the article.
• Type in the “core” of a diagnosis code rather than the complete code (e.g., core of H91.8X1 – H91.8X9 is H91).
• Type in a CPT or HCPCS procedure code.
• Can also search utilizing a descriptor of the diagnosis code or CPT/HCPCS code.
• After completing the search, scroll through the section of codes to determine if the specific diagnosis or procedure code you are looking for is included in the article.
Note: Not every CPT/HCPCS procedure or ICD-10 diagnosis code has an LCD or a billing and coding article. If you do not find what you are looking for, a procedure may have other policies or guidelines besides an LCD. Use the standard web search in the top of our website to search for additional information.
This displays an alphabetical listing of all active LCDs. The applicable CPT/HCPCs codes are listed to the right of each LCD and/or article. Refer to the hyperlinked LCD and/or article for specific information.
The related CPT/HCPCS code tables or related covered diagnoses are located within the corresponding articles. The corresponding articles are linked in the associated documents portion of the LCD, if applicable.
When clicking on the specific LCD and/or article, a license agreement will appear. Please click the accept button located at the bottom of the page. Once you accept the license agreement, the LCD and/or article will populate.
Utilize the medical policy search application on our website or the search box at the top of our website. This will direct you back to the active policy index for currently active LCDs/articles or you can enter search criteria to search within the MCD.
Search the MCD
Within the
MCD search 
you can enter a keyword, CPT/HCPCS procedure code, ICD-10 diagnosis code, or document ID of an LCD or NCD, and select your state. When searching by ICD-10 we suggest that you use only the first three digits (“core”) because a range of diagnosis codes may be listed within a billing and coding article. Click on the “submit search” (magnifying glass) icon. On the next page you can filter further by selecting “Starts With All Words or Any Words”, “Document Types”, “State or all states”, “All contractors or by Contractor number, type, or name” or “More” options. Search results will be based on the criteria entered.
Note: Other Medicare administrator contractors’ LCDs will also appear in the MCD, so pay attention to the contractor information to ensure you are viewing the LCD for your specific contractor.
The Medicare Program Integrity Manual (PIM), CMS Publication 100-08, Chapter 13 directs that Medicare administrative contractors (MACs) have discretion to retire LCDs and articles at any time. Please refer to our
LCD retirement process for more information.
• If an LCD or billing and coding article has been retired, they are still accessible using our Retired LCD and Article list on the
Interactive LCD index • LCDs and Articles that have been retired one year or more are housed on the
MCD Archive.
• If you do not see the LCD or article that you are looking for in our Retired LCD and Article list, try
searching the MCD Archive.
CMS develops NCDs to describe circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an item or service is covered (or not covered) under the § 1862(a)(1) of the Social Security Act or other applicable provisions of the Act. An NCD can be initiated by CMS if it finds an inconsistent local coverage policy, services represent a significant medical advance and no similar service is currently covered by Medicare, service is subject of substantial controversy, or a potential rapid diffusion of an overuse exists.
Components of an NCD
Information that may be contained in an NCD includes description information, benefit category, item/service description, indications, and limitations of coverage and/or medical necessity, claims processing instructions, national coverage analyses, transmittal information, revision history, additional information, procedure codes, covered and/or non-covered diagnosis codes.
Note: CPT/HCPCS, ICD-10 codes are not listed within the NCD.
Helpful hints for NCDs
ICD-10 Diagnosis codes in NCDs
• Finding ICD-10 diagnosis codes within NCDs for laboratory services are located in links at the bottom of the LCD under the heading titled "Other".
• For all other services, locate the NCD transmittal within the
ICD-10 CMS webpage . Within the transmittal there will be a link to the NCD spreadsheet.
Note: Not all diagnosis codes listed in the NCD spreadsheet are covered. A message will appear at the top of the diagnosis listing to indicate denial or coverage if one of the following diagnosis codes are present on the claim.
NCD revisions
Note: If you do not find what you are looking for, a procedure may have other policies or guidelines listed on the CMS website. Continue to locate guidelines on the CMS website.
A procedure can have other policies or guidelines besides an LCD or NCD. The CMS website has a wealth of information. The CMS Internet-Only Manuals (IOMs) are a good source of Medicare information since they display day-to-day operating instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives.
These articles explain Medicare policy in an easy-to-understand format. They focus on coverage, billing, and payment rules for specific provider types. They are prepared with assistance from clinicians, billing experts and CMS subject matter experts.
CMS developed NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payments. NCCI procedure-to-procedure code pair edits apply to services provided on the same date of service by the same physician. Reporting both codes will generally result in the denial of payment for one of the services.
The purpose of the NCCI procedure-to-procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. NCCI contains one procedure-to-procedure table of edits for physicians/practitioners and one procedure-to-procedure table for outpatient hospital services.
An MUE is a maximum number of units of service allowable under most circumstances for a single CPT/HCPCS code billed by a provider on a single date of service for a single patient. MUEs were developed to reduce the paid claims error rates based on anatomical consideration, CPT instructions, CMS policies, and clinical judgment. MUEs are updated quarterly.
Navigate to the MUE edits from the left navigation bar on the
NCCI page.
Note: If you do not find what you are looking for, an item or service may have coverage under the contractor’s LCDs.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
