October 11, 2018

CMS Revamps Medicare Local Coverage Determination Rules

The Centers for Medicare and Medicaid Services (CMS) has revised rules for the development and administration of Medicare Local coverage determinations (LCDs), a powerful set of instructions, policies and procedures governing 

Medicare payment terms applied locally around the country.

CMS’ actions centered on changes to Chapter 13 of the Medicare Program Integrity Manual (PIM), where the LCD process is described. LCDs are administrative and educational tools intended to help health care providers submit correct claims for payment. They specify the clinical circumstances when a clinical item or service is considered to be reasonable and necessary for Medicare patients within a specified geographic region. The CMS Manual also guides stakeholder engagement in the LCD process.

Medical Administrative Contractors (MACs) have been accorded tremendous authority to develop LCDs by considering medical literature, the advice of local medical societies and medical consultants, public comments, and comments from the provider community. The impact of the changes is significant considering 90 percent of Medicare policies are established at local levels.

CMS revised the manual in response to a provision of the 21st Century Cures Act to improve transparency in the LCD process. The update is the first for the manual since August 2015. The implementation date is January 8, 2019.

The manual was reformatted for stakeholders to use a roadmap with a step-by-step description of the LCD process that is accessible to all stakeholders. Such transparency carries through to the reconsideration process. The revisions now enable stakeholders to ask a MAC to take a second look at an existing decision using evidence that has developed since its previous review. And, it also sets forth consistent requirements for provider/stakeholder communications, which now must occur at predictable milestones so anyone with an interest in a LCD’s development can stay informed as it moves through the process.

Other major changes include the following:

  • Consistent presentation of evidence. Standardized summary of clinical evidence supporting LCD decisions and a MAC coverage determination rationale.
    Informal meetings with MACs. Option to request an informal meeting with the MAC to discuss potential LCD requests
  • More voices on Carrier Advisory Committee (CAC). In addition to physicians, other health care professionals (e.g., nurses, social workers, epidemiologists) can participate in the CAC. The CAC also must include beneficiary representation.
  • Relocation of codes. In the future, all International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) codes will be removed from the LCDs and placed in separate articles that will be linked to the LCDs.  

As part of CMS’ commitment to continuous improvement, the agency has invited interested stakeholders to submit feedback on their experiences with the revised LCD process. CMS will collect feedback via submissions to LCDmanual@cms.hhs.gov and will consider additional revisions based on the feedback.

For a full list of changes to the manual, refer to fact sheet “Summary of Significant Changes to the Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations”.

Two relevant publications were released on October 3, 2018. The official instruction, CR10901, was issued to MACs to cover detailed changes to the LCD process and revised contractor instructions. MLN Matters Number MM10901 addresses the change request for LCDs as it applies to Medicare physicians, providers and suppliers.

ACR staff and representatives of the ACR Carrier Advisory Committee (CAC) Network will monitor these changes and continue to advocate on behalf of radiology for fair reimbursement policies at the local Medicare level.