Why and How to Comment on Medicare Local Coverage Determination (LCD)

Under the Medicare program, the government pays only for “medically necessary” services. The Medicare carriers and intermediaries have significant authority, through their medical directors, to define what is “medically necessary.” The method by which this occurs is called a Local Coverage Determinatio n(LCD). Because these can include incorrect or incomplete information, it is extremely important that SVU members be aware of proposed LCDs and actively involved in coordinated efforts to shape them appropriately.

The Medicare program requires that a proposed LCD be published for comment before it is instituted. Proposed LCDs are published in those carrier and intermediary bulletins you receive in the mail. If you do not get them, someone else in the office does, and you should get them and review them carefully. Unfortunately, sometimes proposed LCDs are flawed and need revision. Sadly, ultrasound and other providers too often fail to take advantage of the comment period —and get stuck with an LCD that may inappropriately restrict Medicare coverage for services.

SVU cannot overstate the importance of its members becoming active in commenting on LCDs. With Medicare carriers and intermediaries across the country devising or revising LCDs that affect non invasive vascular testing services, this is a critical issue that touches on vascular technologists’ responsibility to advocate on behalf of the patients they serve. What should you do? Here are some quick tips:

1. PAY ATTENTION to those bulletins for proposed LCDs.
2. Question the use of ambiguous terms and ask (politely) for clarification.
3. Take care to review very critically statements that are described as applying “always,” “never,” “often,” “most of the time,” “almost never,” and the like.
4. Pay particular attention to comments that certain services are “bundled” into other services.
5. Be careful to closely scrutinize the list of proposed “approved diagnoses”—if a diagnosis code is not listed there, Medicare will deny payment as a reflexive matter, so you need to speak now or forever hold your peace.

Most importantly, organize; work with SVU to put together a coordinated response to the LCD. Individual commentators can be dismissed too easily. We recognize that some Medicare medical directors may not give the credence they should to the views of technologists. SVU is developing model letters and policy statements that can be shared with the medical directors and is ready to assist members in preparing comments to medical directors. These comments should be based, wherever possible, on objective criteria and authoritative materials— with attached copies of those mate!rials for easy reference. Comments should be direct, but respectful and courteous in tone. Do not make disparaging remarks about the medical director or the Medicare program. Always keep the patient and quality of care foremost in considering issues under an LCD.

Finally, in reviewing the bulletin, be extremely sensitive to requirements for credentialing or lab accreditation. Typically, the proposal is to permit payment only where there is a credentialed technologist who performs or directly supervises all tests performed by noncredentialed personnel or the lab is accredited. SVU believes very strongly that LCDs should ultimately require certification of all personnel providing non invasive vascular testing. People who provide diagnostic services like these, which are so dependent on the skill and judgment of the personnel performing the service, should demonstrate a minimum entry level of competence. SVU's "Guidelines for Evaluation of Credentialing for Vascular Technologists" defines the components of an appropriate credential. In order to provide for an appropriate transition, we suggest that this registry requirement be mandatory in three years. SVU believes that the standard of a credentialed supervising technologist or lab accreditation should be used until the three year transition ends. Make sure that the credentials referenced in the proposed LCDs are those that SVU supports.

As an example, look at this letter that SVU sent in response to the draft proposed LCD from the Indiana carrier. Because all proposed LCDs will vary to some extent, you will need to adopt this model to your specific situation. Please remember, that no person may indicate that any comments reflect the views of SVU without specifically securing SVU’s approval.