Understanding Medicare Fiscal Intermediaries LCD’s and How They Affect You
Each fiscal intermediary (FI) has the authority to write its own Local Coverage Determinations (LCDs), based on national guidelines. An LCD defines the circumstances in which a particular procedure is covered under the patient’s Medicare benefits. When new procedures are developed, the FI creates an LCD for them. The FI also reviews existing LCDs to decide whether changes are needed because of treatment advances, statistical data, industry standards and similar factors.
How do LCDs affect you?
If you plan a procedure and the criteria of the LCD are not met, you will get a denial very quickly, and then you may wait months for responses to your appeals. If you know the requirements of the LCD, you may be able to avoid the denial. At the least, you can have the exact medical documentation that addresses the likely reason for denial. Most LCDs contain a medical necessity clause. If your documentation shows that the case is an exception to the rule and the procedure is medically necessary, your appeal will likely succeed.
How to find and follow LCDs
The websites of all FIs include an LCD search. You can enter a CPT or HCPCS code to get the most recent version of the LCD. Many FIs also let you sign up for automatic email updates about new or changed LCDs. This also lets you take part in creating or changing an LCD, because the FI holds a comment period before an LCD takes effect.
Medicare contractor LCD websites in 2013
When this paper was published, each contractor below had its own LCD page. The table lists the contractors and their websites at that time.
| Contractor | Website in 2013 |
|---|---|
| Cahaba Government Benefit Administrators | cahabagba.com |
| First Coast Service Options | medicare.fcso.com |
| National Government Services | ngsmedicare.com |
| NHIC | medicarenhic.com |
| Noridian Administrative Services | noridianmedicare.com |
| Novitas Solutions | novitas-solutions.com |
| Palmetto GBA (J1) | palmettogba.com |
| Palmetto GBA (J11) | palmettogba.com |
| Trailblazer Health | trailblazerhealth.com |
| Wisconsin Physicians Service (J5) | wpsmedicare.com |
| Wisconsin Physicians Service (J8) | wpsmedicare.com |
| Wisconsin Physicians Service (legacy) | wpsmedicare.com |
What has changed since this was written
- MACs replaced fiscal intermediaries and carriers. Medicare Administrative Contractors (MACs) now process Part A and Part B claims and write the LCDs for their jurisdictions.
- Every LCD is in one CMS database. You can search all current, proposed and retired LCDs and their billing and coding articles by code, contractor or state in the CMS Medicare Coverage Database.
- Several contractors on the 2013 list no longer exist. Trailblazer Health, NHIC and Cahaba GBA no longer hold Medicare contracts, the WPS legacy and Palmetto J1 jurisdictions were consolidated, and the old LCD page addresses no longer work. The current Part A and B MACs are CGS, First Coast, National Government Services, Noridian, Novitas, Palmetto GBA and WPS.
- The LCD process now has required public steps. The 21st Century Cures Act of 2016 requires MACs to publish proposed LCDs, hold open meetings and respond to public comments before an LCD takes effect.