In change request CR7818, effective October 1, 2014, the Centers for Medicare and Medicaid Services announced that the National Coverage Determinations get diagnosis codes hard-coded as Medicare shared system edits. Those that contain ICD-9 diagnosis codes will be updated with comparable ICD-10 diagnosis codes. This change request was the first of three requests, the other two yet to be published.
All associated edits such as HCPCS/CPT procedure codes, denial messages, frequency edits, Place of Service (POS)/Type of Bill (TOB)/provider specialty editing, etc. would also be updated. CMS emphasized that making the new hard-coded edits does not expand, restrict, or alter existing Medicare national coverage. Additionally, Medicare Administrative Contractors (MACs) will still have discretion to implement NCDs or Local Coverage Determinations (LCDs).
CMS explained that where hard-coded edits were not initially implemented due to time and/or resource constraints, doing so in preparation for ICD-10 implementation serves the intent and integrity of national coverage and the Medicare Program overall.
Diagnosis Code Reporting and ABNs
Given the additional space for reporting eight more diagnosis codes in the Version 5010 electronic transmission standard for health claims, it makes a lot of sense to have hard coded national coverage determinations in order to make it easier both for providers and CMS MACs to make coverage decisions. When a service is not covered for a patient’s condition, a provider can more easily obtain an Advance Beneficiary Notice (ABN) to permit direct billing of the beneficiary. If an ABN is not obtained at the time of the service, the provider cannot appeal the denial due to non-coverage nor bill the beneficiary.
When LCDs and NCDs may have overlapping topics, it will be more clear which particular conditions support coverage. Making these determinations today can be particularly difficult for Medicare Advantage Payers who need to understand multiple sets of LCDs for beneficiaries who receive care into different MAC jurisdictions.