My understanding is that Local Coverage Articles are 'further explanation' of an LCD. So if a state does not have an LCD for a CPT or HCPCS code, we do not need to research further and read any Articles that apply when the same code has an LCD for a different state. For example, J9035 does not have an LCD for Colorado. Therefore, J9035 is the correct HCPCS code for Avastin for part B, Colorado, correct? I am hearing that if there is an Article that addresses my code (even though my state does not have an LCD for it) I have to follow the guidance in the article.
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Question Local Coverage Articles
- Thread starter fhromeo30
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jkyles
True Blue
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Hi there, you should always check for a separate local coverage article. I have occasionally come across LCAs that don't have a companion LCD. This document from CMS explains the different types of coverage documents. www.cms.gov/medicare-coverage-database/help/Document_Type_Descriptions.pdf?t=638285868864536312
amyjph
True Blue
The LCD is the MAC's so if it's not from your MAC, no. However, you would want to check the NCD and LCA as advised above. It doesn't hurt to read them though.
There is an article: Article - Billing and Coding: Bevacizumab and biosimilars (A52370)
Novitas JH (B) has specific info about it: Appropriate drug billing for Avastin (bevacizumab), J9035
There is an article: Article - Billing and Coding: Bevacizumab and biosimilars (A52370)
Novitas JH (B) has specific info about it: Appropriate drug billing for Avastin (bevacizumab), J9035
amyjph
True Blue
I guess it depends on your practice or employer and who is directing that.
However, if there is no LCD for it and no NCD for it, they revert to medical necessity determination as far as I know. So, no, technically you don't follow another state or MAC LCD if you are not billing to that MAC.
However, if there is no LCD for it and no NCD for it, they revert to medical necessity determination as far as I know. So, no, technically you don't follow another state or MAC LCD if you are not billing to that MAC.
jkyles
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Yes, you must follow guidance issued by your MAC. Could you share a link to the LCA you're looking at?
amyjph
True Blue
Wondering about the MAC too, you mentioned Part B Colorado. Noridian is not the MAC for that jurisdiction.
Noridian:
JA Includes: CT, DE, ME, MD, MA, NH , NJ, NY, PA, RI, VT, Washington DC
JD Includes: AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, Am. Samoa, Guam, N. Mariana Islands
JE Includes: CA, HI, NV, Am. Samoa, Guam, N. Mariana Islands
JF Includes: AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY
Novitas:
Jurisdiction L (JL), which spans Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania as well as Arlington and Fairfax counties in Virginia, and the cities of Alexandria, Fairfax, and Falls Church in Virginia for Part B services only
Jurisdiction H (JH), which spans Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, and includes Indian Health Service (IHS) and Veterans Affairs (VA) nationally
When searching J9035 on the CMS coverage database, the only article for J9035 is from NGS, the others are retired.
www.cms.gov
Article ID
A52370
Noridian:
JA Includes: CT, DE, ME, MD, MA, NH , NJ, NY, PA, RI, VT, Washington DC
JD Includes: AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, Am. Samoa, Guam, N. Mariana Islands
JE Includes: CA, HI, NV, Am. Samoa, Guam, N. Mariana Islands
JF Includes: AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY
Novitas:
Jurisdiction L (JL), which spans Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania as well as Arlington and Fairfax counties in Virginia, and the cities of Alexandria, Fairfax, and Falls Church in Virginia for Part B services only
Jurisdiction H (JH), which spans Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, and includes Indian Health Service (IHS) and Veterans Affairs (VA) nationally
When searching J9035 on the CMS coverage database, the only article for J9035 is from NGS, the others are retired.
MCD Search Results
A52370
My state is Hawaii (Noridian Part B) and the HCPCS code is J9035. The drug injected is bevacizumab. There are 3 articles that come up for Noridian, for bevacizumab but all 3 state this at the top of the document "Not an LCD Reference Article. This article is not in direct support of an LCD".
frigodaughter1
New
Use the Nation Coverage Determination (NCD)