National Coverage Determinations and Denials

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This question, speaking of the compliance and regulatory on the NCD (National Coverage Determinations)… • Learn more: https://www.cco.us • Q: “'I'’m seeing a ton of denials for NCD 20.4. Do you have a link to this NCD? I pretty much know this is a diagnostic code issue, just not sure what diagnosis code they are wanting.” • A: I just simply did a Google search on NCD 20.4 and this is what I found. I’m going to do it right now live, NCD 20.4. Don’t be afraid to use Google to do work searches. A lot of people don’t realize that it will yield exactly what they’re looking for. Oftentimes, if you type it in exactly how you’re thinking the question, it will get you even closer to a page that will give you what you’re looking for. • Here it is, it took me right to the cms.gov website 20.4, is the very first hit, it is exactly what I was looking for. That’s the link that they ask for. This one happens to be about the implantable automatic defibrillators. It gives you the policy number, the effective date, and it goes into what it is. It consists of a pulse generator and electrodes for sensing and defibrillating the heart. • Then, here’s what they’re really asking, the indications and limitations of coverage. What is a reason that they can have this device that it would be paid for? If there’s a limitation, then they’ll know what it won’t be covered for. This is a very long and complicated NCD. A lot of times your National Coverage Determinations will result in a local carrier one because they have a contract with Medicare to carry out their decisions, so they would read this and they’d come up with a local carrier one, the LCDs. So, NCD and LCD is often talked about at the same time, but it normally starts with an NCD. • I got this little explanation from CMS itself. Basically, it’s telling us that an NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare doesn’t cover everything. So these will help communicate what they do cover and under what circumstances. • “Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision. Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or a Federal Register Notice.” So, they need to somehow communicate to the public about this coverage determination. • “That issuance, which includes an effective date and implementation date, is the NCD.” And we just looked at what one looks like on their website. “If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment.” Once they determine that it’s going to be covered, then they got to update their billing manual that tells them how to do that. • At any rate, that is what an NCD is. If you have an encoder like Find-A-Code, they will also include the NCD, so I went and looked for it today and if you go to Find-A-Code, it’s under their info menu, Medicare and then NCD. I made a little quick link so we could jump right to it… • This is where they list out all the NCDs and so the one we were looking at was I think 20.4, it’s in the cardiovascular system. These are all hyperlinked and then we’ll expand. Here it is, 20.4, we could just click on that. I’m not signed in, that might be helpful… • This is what theirs looks like. It’s going to give you the header from what we just saw on the CMS website, there’s a transmittal you can go right to that PDF. It gives you the coverage guidance, is what we were just talking about, the indications and limitations. • Coding information – these all say non-listed currently. I actually talked to Taylor from Find-A-Code today via email. He said this has been a project that they’ve been working on, they hope to be releasing it in the first quarter of 2018 where you’ll actually see some codes that they’re letting you know would be covered. Kind of like how they do for LCDs. The problem with NCDs is they give generic information. They don’t link it to diagnostic codes. • Like here, they’ll say coronary artery disease with a documented prior MI. What is that in an ICD-10 code? That’s what we’re looking for. That’s what the questionnaire was saying, I’m sure it has to do with the diagnosis code. I am, too. You probably don’t have a covered indication that you’re submitting. So, the answer is, unfortunately you have to really kind of slug through this and figure out if your patient you’re trying to bill this for has one of these indications. If they do, then you might have to appeal that denial. That’s pretty much how that works. • • • National Coverage Determinations and ...

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