I was told during a Novitas webinar the following regarding coverage:
A procedure can have other policies or guidelines besides an LCD (not an all inclusive list of places to check):
1)MAC website
*Look for a Billing & Coding Article on the MAC Website by doing a standard search
*Check the status indicator on the Fee Schedule (JH)(JL)
2) CMS website:
*Review the NCDs
*Search the CMS Manual for instruction
*Review the National Correct Coding Initiative (NCCI) and Medially Unlikely Edits (MUE) edits on CMS website
*Search for Medicare Learning Network (MLN) articles
3) If no results, Reasonable and Necessary Guidelines
(JH) (JL) still apply in accordance with
The Social Security Act 1862
(a)(1)(A) :
*Services are safe and effective
*Services are not experimental or investigational
*Services are appropriate, including the duration and frequency
*Providers should report the most appropriate ICD-10 code that adequately describes the patients medical condition at the
time of the service and documented clearly: Ensure the medical necessity is supported in the documentation
*All services furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of illness or
injury or to improve the functioning of a malformed body member