Local coverage determination

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Hi, I'm looking for some help. I received a denial from Medicare stating the dx we used wasn't listed under LCD policy. It was pointed out to me that the codes was no good because it was listed under group 7 codes. What exactly does that mean?

Thanks!
 

cgaston

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Every LCD has an explanation in the beginning of the document.

For example, LCD A52850 is regarding Cardiac Catheterizations. In it, they explain that in order for a specific code to be considered medically necessary that code must be billed with diagnoses from specific group(s) which are then listed.

Code 93458 must be billed with a diagnosis from Group 2 and a diagnoses from Group 3 on the list in order to be considered medically necessary. You then look on the list under group 2 and group 3 to make sure that the diagnoses the doctor listed on your procedure note are on those two lists. If they are not, then the service won't be considered medically necessary by Medicare and Medicare will deny the service.

So whatever LCD you are referencing must have the same criteria: the specific code you are billing for must have diagnoses from a specific list which will all be included in the specific LCD. You will have to search your local Medicare carrier (NGS, Novitas, etc) to find the LCD they are referencing (either by the number or by the name of the service).
 
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Thank you for the quick reply. I don't remember the cpt code but it was for a sebaceous cyst (vulva). Primary dx used was L72.3 and that was denied, I used L29.8 as the primary. I will look for that cpt code so I can be more specific. Thank you so much for the replies!!!
 

trarut

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Were you given the LCD number being referenced for the denial? Include that if you were because it will help too.
 
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