1st Apr

Do you LCD? Lie Comfortably Down? Lift Crusty Dumpsters? Learn Creative Dancing? Limited Carb Diet? If you do any or all of these things, good for you, but that’s not what we mean in this instance. LCD=Local Coverage Determination

A Local Coverage Decision is a determination by a Medicare Administrative Contractor (MAC) regarding whether or not a particular item or service is covered as medically reasonable and necessary. It is the responsibility of the clinician to know which MAC is responsible for your facility and understand coverage limitations and requirements as laid out in its corresponding LCD. A MAC is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B medical or DME claims. MACs cover specific states and it is important that you confirm which MAC is responsible for processing claims with your customer, as they can vary based on corporate billing practices.

Why should I know, why should I care?

Because you supply services to a provider that submits claims to Medicare, you should be aware of any coverage policies that might impact how you provide, document and bill for those services. These coverage policies are often established by your local Medicare contractor. A better understanding of these local policies can reduce your risk for claim denials.

  • LCDs identify which services (CPT codes) are covered and reimbursable
  • In the absence of a NCD (National Coverage Determination) MACs can establish their own coverage policies. (NCD is nationwide determination of whether Medicare will pay for an item or service. Coverage is limited to items and services that are considered “reasonable and necessary” for the diagnosis or treatment of an illness or injury),
  • In some instances, MACs provide guidance on which CPT codes are medically necessary for which ICD-10 codes
  • Documentation requirements are delineated with specific information that must be included in patient record to justify coverage of services
  • MACs may provide guidance on frequency and duration
  • CPT and ICD-10 codes provide the basis for coverage or denial by the MAC
  • LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary. Their guidance assists providers in submitting correct claims for payment. The MAC’s medical review department utilizes the LCD for guidance to assist in their coverage and coding audits of claims.

It is important to note that each LCD may have different information/definitions/explanations for codes.

In summary, understanding Local Coverage Determinations – Reduces risk for claim denial, Assures compliance with documentation requirements, and Provides a framework for developing best practice for quality service delivery

Here is a list of MAC’s and the states they cover:

Palmetto GBA: NC, SC, GA, AL, TN,VA, WV                               First Coast: FL

WPS*: IA, KS, MO, NE, IN.                                                                Noridian*: AK, ID, OR, WA, AZ, MT, ND, UT, WY.

CGS**: KY, OH                                                                                      NGS: IL, MN, WI, CN, NY, MN, MA, NH, RI, VT


* Note: This MAC does not have LCD for PT, OT, ST-it defers to the NCD (National Coverage Determination).

**Note: The SLP LCD does not address Dysphagia

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