CMS mandates changes to Local Coverage Determination (LCD) policies

Oct. 5, 2018 / By Barbara Aubry, RN

On October 3, 2018, CMS released CR 10901, Transmittal R829PI, effective October 3, 2018 with an implementation date of January 8, 2019. This is an important modification to the LCD process and the first update to Chapter 13 in the Medicare Program Integrity Manual since 2015:

In CR10901, the revisions to the Medicare Program Integrity Manual, Chapter 13, CMS is revising instructions to MACs, reflecting policy process changes in response to the new statutory (21st century Cures Act) requirements and to the stakeholder comments. 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 2016 21st Century Cures Act included changes to the LCD process, adding language to 1862(l)(5)(D) of the Social Security Act (the Act) to describe the LCD process. Section 1862(l)(5)(D), of the Act requires each MAC that develops an LCD to make available on their Internet website on the Medicare website, at least 45 days before the effective date of such determination, the following information:

– Such determination in its entirety
– Where and when the proposed determination was first made public
– Hyperlinks to the proposed determination and a response to comments submitted to the MAC with respect to such proposed determination
– A summary of evidence that was considered by the contractor during the development of such determination and a list of the sources of such evidence
– An explanation of the rationale that supports such determination

The revamped manual format will act as a “roadmap to understand the steps of the local coverage process, which enables stakeholder to effectively engage in the process” which increases transparency through the reconsideration process as well.

The changes are important to those who are invested in coverage modifications based on newer clinical studies and especially for newly released treatments. Hopefully, the new process will:

  1. Support a transparent roadmap that provides a consistent presentation of evidence standardized to support LCD decisions and coverage rationale. This also includes an opportunity to request an informal meeting with MACs to discuss potential LCD requests.
  2. Creation of a new LCD request process and a restructured Contractor Advisory Committee (CAC) meeting process to include meetings open to the public. CMS will also increase in the types of voices heard during CAC meetings including other healthcare professionals (nurses, social workers, epidemiologists, etc.) as well as beneficiary representation.
  3. Retirement of “old” proposed polices that have not been enacted within one year.
  4. Increased public communication by the MACs to include replies to public comments linked to a final LCD that must remain in the Medicare Coverage Database archives, as well as public notification when a MAC published a final decision, including a link to the policy.
  5. CPT and ICD-10 codes will be removed from policies.
  6. The reconsideration process must be consistent with the National Coverage Determination Reconsideration process.

My Take

It’s important to understand that a change in the LCD process does not mean all policies for the same service will be identical. CMS continues to recognize the practice of medicine can differ based on geographic location. Staying current with coding changes in the policies is a must, but it appears it may be a bit easier to know when changes occur with public notification. I am a bit concerned that the polices will no longer include ICD and CPT codes, as that means one place to read the policy rules and another to find the codes. The notification documentation states “all CPT and ICD-10-CM codes shall be removed from the LCDs and placed in billing and coding articles or Policy Articles that are to be published to the MCD (Medicare Coverage Database) and related to the LCD. CMS will provide additional instructions on the date upon which this change will be effective.”

This results in another document or moving part that has to be coordinated which doesn’t make the task of tracking the medically necessary code change any easier…stay tuned.

Barbara Aubry is a senior regulatory analyst for 3M Health Information Systems.