skip to Main Content
Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, June 27, 2011 Posted in: Outpatient Rehab

If your Fiscal Intermediary, Carrier or Medicare Administrative Contractor is National Government Services (NGS) this post is for you!  The 98 page Local Coverage Determination (LCD) should guide documentation standards to align with expected “reasonable and necessary” information to support your billing codes and was updated in February, 2011.

LCDs come in all shapes and sizes for every type of provider. LCDs are important enough that they have an entire chapter of explanation provided in the Medicare Program Integrity Manuals.  Chapter 13, to be specific – and need I say more?  By definition,  “An LCD is a decision by a Medicare administrative contractor (MAC), fiscal intermediary or carrier whether to cover a particular service on a MAC-wide, intermediary wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary.) The difference between LMRPs and LCDs is that LCDs consist of only “reasonable and necessary” information, while LMRPs may also contain benefit category and statutory exclusion provisions.”  Section 13.1.3

Just as other rules, LCDs start out as a comment or intention to define specific medical necessity, and are adopted by various Medicare Administrative Contractors.   Many professional organizations made comments on the initial draft of the OP LCD, helping to impact change in the final version.  LCDs provide guidance on various codes that will or will not be covered and describe “reasonable and necessary” conditions for payment.

Inherent in the vast number of pages published for the OP LCD by NGS is a great compendium of all regulations specific to outpatient practice, making the information a rich guidefor documentation guidelines found within various Medicare Manuals and publications.

Even if your jurisdiction has not adopted the LCD, it remains an excellent source that is very helpful for young and seasoned clinicians alike to refresh expectations for various billing codes. If you read intently, you will see that the definition of skilled intervention, expected and probable improvement as well as significant impact in the reduction of functional impairment that limits a beneficiary’s ability to maintain independence, is key to defining the appropriate covered service.  The LCD even defines expectations for the total number of charges dropped by a specific code that would question the likelihood of that service having the impact expected.

In order to view the LCD page by page, you will need to download it as a pdf file.  Pages 11 to 58 discuss various current procedural terminology (AMA),  in a granular fashion to indicate expected documentation for each of the codes billed. Page 77 reviews progress reports and treatment notes along with expected differences.  Page 79 discusses discharge and leads to page 80 which outlines certification and recertification requirements.

If you adopt a chart audit process, this document again is an excellent resource for planning expectations for documentation and to measure the information contained within that is ultimately transferred to the uniform billing document resulting in payment.

Back to top