CMS: LCD Exceptions May be Warranted

October 5th, 2009

The Centers for Medicare & Medicaid Services (CMS) issued, Sept. 25, new guidance that delegates Medicare contractors the authority to make an exception to clinical criteria described in a local coverage determination (LCD) on a case-by-case basis and even reconsider an LCD if evidence upholds necessity.

Carriers, fiscal intermediaries (FIs) and Medicare Administrative Contractors (MACs) create LCDs to establish uniformly whether or not a particular item or service is covered.

This may lead you to believe that there is no room for negotiation. On the contrary, CMS says in Transmittal 303, “in rare and unusual circumstances during complex medical review MACs, FIs and carriers have the authority to apply an exception to the clinical criteria described in an LCD” to approve or deny individual claims.

Note that this power does not extend to recovery audit contractors (RACs), who may generally only take advantage of the exceptions process to “not deny” a claim.

An exceptions request is evaluated based on the contractor’s thorough review of the patient’s medical record and other pertinent information.

“Most likely the exceptions to the LCDs would have to be made during the appeal phase,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions. “Thorough review of the patient’s medical record is not available in the initial payment phase.” (Coding News)

If an inordinate number of exceptions are made to clinical criteria in a particular LCD, indicating circumstances are not so “rare and unusual,” contractors have the authority to reevaluate the LCD. In the past, the only way to get an LCD changed was to go to the Carrier Advisory Committee (CAC) and state your case, Cobuzzi notes. (Coding News)

For complete details, read Transmittal 303, Change Request 6586, issued Sept. 25.


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