National Coverage Determinations (NCD) - Medicare regulations allow the Center for Medicare and
Medicaid Services (CMS) to develop coverage policies for Medicare-covered tests and procedures. These
coverage policies, called NCDs, provide definitive guidance to providers concerning the medical necessity
requirements of a particular test or procedure. Numerous NCDs are in effect for a wide array of tests and
services including procedures performed by diagnostic service providers, such as radiologists and clinical laboratories.
Local Coverage Determinations (LCD) - Medicare contractors have the regulatory authority to develop local coverage determinations.
Unlike NCDs, these policies only apply to a single contractor jurisdiction. In the past, local policies were referred
to as Local Medical Review Policies (LMRPs).
Local Coverage Articles (LCA) - Medicare contractors have the regulatory authority to develop local coverage articles.
Unlike NCDs, these policies only apply to a single contractor jurisdiction.
Correct Coding Initiative (CCI) edits are used by Medicare to deny claims based on inappropriate CPT code usage.
CCI edits consist of pairs of CPT codes that Medicare has determined are not payable when performed together.
If a provider submits a claim containing two CPT codes that are the subject of a CCI edit, the Medicare carrier or
intermediary will deny one of the CPT codes. Many CCI edits may be overcome with the proper use of a CPT code modifier.
This information is provided as a convenience for Siemens Healthcare employees and users by
CodeMap®. CodeMap® is responsible
for the accuracy of all content. While every effort is made to ensure that all payment amounts and
regulatory information is current and complete, it is the responsibility of each user to verify
specific coverage and payment information with their Medicare contractors. Actual reimbursement
for healthcare facilities will vary depending on the specific location, the number and type of
clinical procedures performed, and the local carrier coverage and payment policies. Note also
that the federal statute known as the Stark Law imposes certain requirements that must be met in
order for physicians to bill Medicare/Medicaid or other federal healthcare programs for in-office
services provided. In some states, similar laws cover billing practices for all patients.
Additional licensure, certificate of need, and other restrictions may be applicable.
It is the responsibility of each physician, physician group, and other individuals and entities
to consult with their reimbursement manager or healthcare advisor, as well as legal counsel,
to ensure all requirements have been met to support appropriate billing for Medicare services
provided.
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