National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) are Medicare’s coverage policies that describe medical necessity for certain services.

Private payers publish their own coverage policies on their Web sites.

When services are denied due to medical necessity, no pre-authorization, failing to try less expensive or invasive treatments, this is a good indication there is a coverage policy.

What’s in a policy?

Example – One MAC’s Wound Care Policy

• Medical necessity: Brief statement that all services must be medically necessary.
• Coding: Describes who may perform the service (physicians, NPs, PAs, Clinical Nurse Specialists). Discusses incident to guidelines briefly.
• Lists specific codes 97597, 97598, 97602, and states these codes can’t be used for only a dressing change.
• States this about evaluation/re-evaluation: In general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable. Initial wound assessments that are medically necessary may be reimbursable as a separately identifiable Evaluation and Management (E/M) service or, i.e., physical therapy evaluation CPT^® 97001.
• Discusses incident to services, services provided by therapists, E/M and modifier 25, and gives a citation to the Medicare Claims Processing Manual.
• Further sections discuss whirlpool, debridement, unna boot application, high pressure dressings.
• Lists sources.
• Most policies also list covered indications (ICD-10-CM codes).