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Overview of Coverage Determinations
Medicare issues National and Local coverage determinations. These documents specify guidelines for code use. Many list ICD codes that justify the medical necessity of either a service the physician wishes to perform, or a test that might enhance the delivery of patient care through better diagnosis or monitoring.

There are two types of coverage determinations:

-National Coverage Determinations (NCDs) As you might expect, these have a national reach and supercede any local policies. The NCDs that include ICD codes are those that primarily cover laboratory services and are regularly reviewed and updated within the Flash Code software

-Local Medical Review Policys (LMRPs) are now being replaced by Local Coverage Determinations (LCDs). These are issued by the medical director on a state by state basis. Some states have more than one area, with different carriers and LMRPs.

How they work:

Once a coverage determination is issued, it becomes the provider's responsibility to know of any procedure codes that are affected, plus know if the ICD code they have matched to the procedure codes for billing is on the list of codes that justify the procedure.

If the ICD code does not justify the procedure that is to be performed, the provider must inform the patient that medicare will not pay for the service and have the patient either:

-sign a form that allows the physician to bill the patient for the test separately OR
-have the patient decline having the test performed since it will not be covered.

The first form mentioned is called the Advanced Beneficiary Notification (ABN) form.

Remember, all of this has to be done BEFORE the test is performed! If the test gets done, and the ICD code is not on the approved list, medicare will not pay, and will not allow you to bill the patient after the test or procedure has been performed.

Nationwide there are over 14 million ICD to CPT code combinations that we have extracted into Flash Code---all accessible at the click of one button. Here's how we make this easy