A local coverage determination is a decision made by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with section 1862(a)(1)(A) of the social security Act. For example, it involves the determination as to whether the service is reasonable and necessary. Local coverage determination deals only with the most important and reasonable information that is required, incase of any unreasonable and necessary information a contractor desires to communicate to providers must be performed through an article.
Due to the outcome of the Benefits Improvement and protection Act of 2000, all local medical review policies had to be transformed to Local coverage determination. Local coverage determination may also make a decision on whether a particular service is to be covered on an intermediary-wide or a carrier-wide basis. However, it does not cover determination on which procedure code must be assigned to a specific service, or a determination with respect to the amount of payment to be made fro the service offered.
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Medical necessity ensures that there is no Medicare payment that shall be made for products or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Therefore, to ensure that the services being paid are medically necessary, the national coverage determinations and the local coverage determinations have been developed by the centers for Medicare and medical services. Even though local coverage determinations need to be consistent with national coverage determinations, LCDs provides guidelines to contractors on how to review claims in order to determine if Medicare coverage requirements have been fulfilled.
The procedure for developing the local coverage determination involves developing a draft local coverage determination focusing on medical knowledge and the contractor's understanding of local practice. Therefore, through this, the community providers have to be trained and educated on new or significantly the revised local coverage determinations, for instance, the ways in which to communicate to the society meetings or writing articles in the newsletter created by the society. The local coverage determination affects the way of billing medical necessity in that, through it, contractors are encouraged to make applications to the local coverage determination to make claims on either a pre-payment or post-payment basis. Incase a client desires to reinforce a local coverage determination on a pre-payment basis, he or she must design a medical review edit.
Contractors have the authority and are free to make additions, alterations, or subtractions made on medical review edits at any given time. When conducting medical review, contractors are supposed to apply local coverage determinations pre-payment or post-payment for directed claims reviews with inclusion of dates of service on or after the effective date of the policy (Green 90). Contractors are not supposed to make applications of an LCD retroactively to claims processed prior to the effective date of the policy. But, if National coverage determination, coverage provisions in the interpretive manuals and local coverage determination fail to address an issue of coverage foe a give claim, contractors have the permission to make coverage determinations based on the information given. Therefore, local coverage determination affects the ways we bill for medical necessity by allowing us to make applications for the reasonable and necessary claims concerning either a pre-payment or post-payment basis.
Local coverage determination is in most cases the administrative and educational tools that are used to assist providers in the submission or applying for the right claims fro payment. Local coverage determinations involves the codes describing what is covered and what is not covered. For instance, these may include lists of HCPCS code that spell out which services the local coverage determination applies to, lists of ICD-9CM codes for which the service is covered, and lists of ICD-9CM codes for which the service is not give consideration whether it is necessary and reasonable (Jost 78). It is thus advisable that these coding decryptions are only included if they are part to the discussion of medical necessity. However, it should be noted that coding guidelines are not integral part of local coverage determinations and should be printed in articles or eliminated. There addition in local coverage determination is likely to cause confusion to the public and they can be challenged under the 522 provision.
Through a local coverage determination, contractors or clients are required to list the specific date on all retired LCDS. This means that they are supposed to have a mechanism for retrieving retired local coverage determinations. The mechanism may include hardcopy, electronic or web based. The mechanism used should be in position to allow the client to react to requests and retrieve the local coverage determination that was in effect on any given day. Therefore, after getting the necessary information, clients are supposed to post on their web site the necessary information regarding how to get retired local coverage determinations.
Local coverage determination also provides alternative services to be tried first. For instance, it encourages the contractors to incorporate into LCDs the idea that the use of an alternative item or service increases the use of another product or service. This method is referred to as the prerequisite. Therefore, it is the responsibility of the contractors to base any requirement on evidence that a particular alternative is safe, more efficient, or more appropriate fro a given condition without exceeding the patients' medical necessities. Prerequisites therefore, are supposed to focus on the appropriateness of the medical needs, but not on cost effectiveness. Although non-covered products like pillows to rise the feet may also be included. Any alternative medical service for drug therapy should be consistent with the national policy bases coverage on an assessment of the needs by the beneficiary's, providers, but they are not supposed to be included in local coverage determinations. As an alternative, the contractor are supposed to use alternative phrases in the proposed local coverage determinations ,for instance, the provider should consider using safe and appropriate medical services to meet the medical necessities.
Local coverage determination enhances the elimination of the coding guidelines from the LCD in order to enable contractors to speed up the procedures of releasing draft and final coverage decisions because the medical directors can focus on the medical necessity of the service addressed in the local coverage determinations. The contractor medical director is not supposed to tell the providers on how to code or bill in a local coverage policy. This is because contractor medical directors are not specialized in the coding education. However, with the new local coverage determination, that section that required description of the service to be addressed has been eliminated completely. The information in that section is currently included in the section on indications and limitations of coverage and medical necessity.
Local coverage determination effects in the way billing for medical necessity by specifying under what clinical circumstances a service is taken to be reasonable and necessary. This is done through the availability of administrative and educational tools the provide assistance to the providers in submitting correct claims for payment purposes. Contractors also make necessary publications to the local coverage determinations to offer in order to offer guidance to the public and medical staff within their jurisdictions. Understanding the Medicare coverage indications is not always easy, even though they are described by the contractors in the local coverage determination in black and white print. Therefore, it takes serious review of the covered code combinations and searching the policy for other special instructions and limitations.
It is good that all the guidelines are met in order to give better support to medical necessity for the services. To achieve this, the contractors are progressively updating their local coverage determinations so that they are in compliance with the changes in Medicare rules and regulations as well as differences in clinical standards and new technology. According to (Commerce Clearing House 45), updating changes in coverage is important because some policies do not have limitations or special guidelines for frequency, age, or a requirement for dual diagnosis codes. There are number of policies that do not change and they are easily understood by the contractors. Updating coverage also ensures that items, drugs and services provided are covered well by Medicare.
Local coverage determination is a decision made by a fiscal intermediary or Medicare carrier about the services that are necessary and reasonable. Making determination of medical necessity is always not easy and can be very complex. Medical necessity ensures that there is no Medicare payment that shall be made for products or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Therefore, to ensure that the services being paid are medically necessary, the national coverage determinations and the local coverage determinations have been developed by the centers for Medicare and medical services. Local coverage determination has affected the way we bill for medical necessity by specifying clinical circumstances a service is taken to be reasonable and necessary. This is done through the availability of administrative and educational tools that provide assistance to the providers in submitting correct claims for payment purposes.
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