Basic HTML Version
AASM Membership Sections Newsletter Issue #1
19
Medicare Policies
National Coverage Determinations (NCDs)
• Originate from Centers for Medicare and
Medicaid (CMS) – provide high level
determination if service will be covered or not
covered
• Apply to all Medicare jurisdictions
Local Coverage Determinations (LCDs)
• Are contractor-developed coverage policies
pertaining to services or items not addressed in
NCDs or program manuals
• Contain coding and utilization guidelines and
descriptive passages
• Sometimes contain CMS language, which is
italicized
• Are developed to:
◦
◦
Define the appropriate the use of new
technologies
◦
◦
To address services with an abuse history or
potential
◦
◦
To monitor high volume, high dollar services
• Are subject to the Carrier Advisory Committee
(CAC) and public comment period
• Can be readily revised as new data becomes
available and is supplied to the Contractor Medical
Director
• May have “Coding Instructions” and/or “Reasons
for Denial” which appear in a companion article
– look under “LCD Attachments” in the policy to
determine whether there is a companion article
LCD Advisory Process
Purpose of the Carrier Advisory Committee (CAC)
• A formal mechanism for physicians in the state to
be informed of and participate in the development
of an LCD in an advisory category
• A mechanism to discuss and improve administra-
tive policies that are within carrier discretion
• A forum for information exchange between carri-
ers and physicians
Documentation
Documentation Requirements related to
• Evaluation and Management services
• Specific sleep medicine testing codes
• Medicare policies
References
Search For State Medicare Policies
Evaluation & Management Documentation
Guidelines (1995 &1997)
Carrier Advisory Committee (CAC) Information
Resources
AASM Health Policy
AASM Coding and Compliance
Coding, Compliance, and Health Policy Education
Many members have asked questions regarding the Centers for Medicare and Medicaid Services (CMS) policies on
sleep consultation and testing. Below is a brief summary of the types of polices CMS and local CMS-contractors issue
with references for further study.