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Understanding local coverage determinations

As a healthcare provider in San Antonio, your primary concern is the health and well-being of your patients. It is difficult to manage that, however, if you are not getting reimbursed for the services that you perfom. Many practitioners in your position have come to us here at The Law Office of Jessica Taylor PLLC wondering what they can do to avoid having to deal with the hassle that comes with claim denials. Given that your expertise likely does not lie in medical coding and reimbursement, you may have no idea exactly what insurers want to see on claims. That is where understanding local coverage determinations comes in handy. 

According to information shared by the American Physical Therapy Association, LCDs are coverage guidelines created by your local Medicare administrator (in Texas, ours is Novitas Solutions). A coverage determination details the documentation and coding requirements of a procedure. If your claim does not meet the guidelines set by an LCD, it will likely be denied. There are three different types of LCDs: 

  • Final: These have an effective date and a specified coverage area
  • Draft: These are updates to existing final LCDs
  • Retired: These are achived guidelines that are no longer active

You can access your region's LCDs through Medicare's website. 

Understanding LCDs can help you know what documentation is required with a claim's submission and what criteria and diagnoses are needed to determine whether a procedure is considered medically necessary. While these are rules established for Medicare plans, many commercial carriers follow Medicare's reimbursement methodologies, while others model their coverage determinations after LCDs. Thus, being familiar with them may assist you in ensuring both government and commercial claims are paid. 

You can find out more about physician ERISA issues by continuing to browse through our site. 

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The Law Office of Jessica Taylor, PLLC

The Law Office of Jessica Taylor, PLLC
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