CMS Revises LCD Process
Your Turn for Action
The second week of each month the Wednesday@One newsletter provides updates on new, retired, and draft Local Coverage Determinations (LCDs) from the Medicare Administrative Contractors (MACs). LCDs are determinations by a MAC as to whether or not a particular item or service is covered (reasonable and necessary) on a contractor-wide basis. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD. LCDs contain only reasonable and necessary conditions of coverage. MACs publish other information such as coding and payment guidelines in a related complementary article.
Local coverage policies, currently known as LCDs and their predecessor LMRPs (local medical review policies) have been around for years and CMS provided guidelines for LCD development in Chapter 13 of the Medicare Program Integrity Manual. However, stakeholders expressed to CMS concerns about lack of local coverage process transparency, specifically
- Notification to stakeholders of proposed revisions to, and drafting of, new LCDs;
- Ineffective MAC processes for soliciting from, and providing to, stakeholders feedback on information provided during open public meetings;
- A lack of non-physician representation on Contractor Advisory Committees (CACs); and
- CAC meetings not being open to the public.
In response to these concerns, CMS is revising the LCD process and updating the Medicare Program Integrity Manual instructions. Per the MLN Matters Article MM10901 that details these revisions, “these changes will help to increase transparency, clarity, consistency, reduce provider burden and enhance public relations while retaining the ability to be responsive to local clinical and coverage policy concerns.” The revised manual instructions provide a roadmap to the steps of the LCD process and enable stakeholders to effectively engage in the process.
The LCD process can begin with informal meetings to discuss potential LCD requests although this is not required. LCDs may start with a formal request through the New LCD Request Process. Requests may be made by beneficiaries, healthcare providers/professionals, or other interested parties receiving care or doing business in the MAC jurisdiction. The LCD request must:
- Be in writing and sent via email, fax, or letter;
- Identify the Medicare benefit category;
- State the language the requestor wants in the LCD;
- Include a justification supported by peer-reviewed evidence;
- Address relevance, usefulness, and medical benefits/outcomes of the item/service; and
- Explain the design, purpose, and/or method of using the item/service.
MACs have 60 days to determine if the request is complete or not. If it is, they proceed with the LCD process; if not, they will notify the requestor in writing as to why the request was incomplete.
MACs will consider the information provided in the request along with clinical guidelines, consensus documents, and opinions of healthcare experts, medical associations, and healthcare professionals to form their proposed determination. A summary of the information considered will be included in the draft LCD. Once a draft LCD is published, the MAC will hold meetings to discuss the LCD and accept public comments for at least 45 days.
One meeting is with the Contractor Advisory Committee (CAC) – a group of healthcare professionals, beneficiary representatives, and representatives of medical organizations that supplements the MAC’s internal expertise. Each state in a jurisdiction will be represented and CAC meetings will be open to the public. Per the MLN article, “The CAC’s purpose is to provide a formal mechanism for healthcare professionals to be informed of the evidence used in developing the LCD and promote communications between the MACs and the healthcare community. The CAC is advisory in nature, with the final decision on all issues resting with MACs.”
There will also be Open Meetings to discuss the evidence and rationale of the proposed LCDs. MACs must notify the public about the dates and location for the open meetings. Interested stakeholders, such as providers, physicians, vendors, manufacturers, beneficiaries, caregivers, etc. can present information at these meetings. After the required meetings and the end of the comment period, the MAC will publish a final LCD. An accompanying “Response to Comment” article that addresses the MAC’s response to all comments received will be published on the same day as the final LCD and will remain publicly available indefinitely. There will be at least a 45-day Notice Period beginning when the LCD is published. The LCD will not become active until the end of the Notice Period.
There is also a Reconsideration Process available where beneficiaries, providers, or interested parties may request revisions to final effective LCDs. Two other significant changes to the LCD process are:
- MACs must finalize or retire draft LCDs within one calendar year of their publication on the Medicare coverage database (MCD).
- CPT procedure and ICD-10 diagnosis codes will no longer appear in LCDs. They will be included in billing and coding articles that are linked to the LCD.
Those are the facts but here are some of my thoughts. I appreciate that CMS has taken steps to make this process more transparent and inclusive of all stakeholders. However, that now puts the onus on the stakeholders to actually do something! Request an LCD if you know of a service that needs one, look for and read draft LCDs, provide comments, attend the open meetings and give input, etc. Many years ago, when I worked in hospital compliance, my area contractor held meetings to discuss proposed Part A LCDs. A few topics (rehabilitative therapy for example) garnered a large engaged audience, but most meetings were attended by only a sparse few with even fewer, if any, comments. CMS has done their part to make the process better, now it is time for providers to step up, take action, and be involved.
LCD updates since last month are listed in the table below:
Article by Debbie Rubio
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.