This lesson provides an overview of the Centers for Medicare and Medicaid Services (CMS) national and local coverage issues for services payable under Medicare Part B. The lesson will define the difference between local coverage determinations (LCDs) and national coverage determinations (NCDs), what coverage determinations are, why they were developed, and how they are used, and provide resources to obtain further, detailed information both nationally, and by state. Medicare provides access to a database that contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local articles, and proposed NCD decisions. This database can be found at https://www.cms.gov/medicare-coverage-database/.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.5000 contact hours.
Section 1: Introduction
About This Course
Section 2: Coverage Determinations
Purpose of a Coverage Policy
What Is Medical Necessity?
Section 3: NCDs
National Coverage Determinations
NCD Edits Updated Quarterly
Lab NCD Manual
Lab NCD Manual Example
ICD-10-CM Code Table Example
Coding Guidelines for All NCD Edits
Noncovered ICD-10-CM Codes for All NCD Edits
Noncovered ICD-10-CM Codes for All NCD Edits: Examples
Reasons for Denial
Section 4: LCDs
Local Coverage Determinations
Example of LCD by State Index
Determining Effective Coverage Decisions
Section 5: Conclusion
Expert Reviewer: Jean C. Russell, MS, RHIT
Richard has more than eighteen years in healthcare consulting. He has developed an expertise in hospital outpatient and inpatient coding, including professional split billing and E/M coding, admission criteria, reimbursement and compliance, and charge master reviews. His areas of expertise include Medicare reimbursement for the Medicare Outpatient Prospective Payment System (OPPS), Medicaid Ambulatory Payment Groups (APGs), as well as commercial payers, and professional reimbursement. He is a certified coder with AHIMA (CCS). Richard earned his Bachelors from Hobart College.Disclosure: Richard R. Cooley, BA, CCS has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Jean Russell has over thirty years of healthcare and information system experience. Her areas of expertise include the Medicare outpatient prospective payment systems (APCs, and APGs), as well as ICD-10-CM/PCS training, Charge Description Master (CDM), admission status reviews, and outpatient coding and compliance. She is a frequent speaker at the national, state and local levels for HFMA and AHIMA professional groups. Jean has her Masters from the University of Houston in Biomedical Engineering; her Bachelors from Colgate University in Biology; and her RHIT from the independent study program through the American Health Information Management Association.Disclosure: Jean C. Russell, MS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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