What Is LCD / NCD (Local & National Coverage Determinations)?
An NCD is a nationwide CMS coverage policy specifying whether Medicare will cover a service; an LCD is a coverage policy issued by a Medicare Administrative Contractor (MAC) for its jurisdiction when no NCD applies, defining medical necessity criteria and covered diagnosis codes.
- CARC 50 (not medically necessary) denials almost always trace back to an LCD/NCD criteria failure.
LCD / NCD (Local & National Coverage Determinations)
Also known as: Local Coverage Determination; National Coverage Determination; Medicare Coverage Policy
An NCD is a nationwide CMS coverage policy specifying whether Medicare will cover a service; an LCD is a coverage policy issued by a Medicare Administrative Contractor (MAC) for its jurisdiction when no NCD applies, defining medical necessity criteria and covered diagnosis codes.
Definition
NCDs are published by CMS in the Medicare Coverage Database under section 1862(l)(6) of the Social Security Act, are binding on all MACs, and apply nationwide. LCDs are issued by individual MACs and apply only within that MAC's jurisdiction. LCDs typically include covered ICD-10 diagnosis codes, frequency limits, documentation requirements, and noncovered indications. Both NCDs and LCDs go through public comment processes. Article documents (formerly LCAs) often accompany LCDs with billing and coding details. Most commercial payers have analogous medical policies, and many specifically reference Medicare LCDs/NCDs as their coverage standard.
Example
Medicare's NCD for screening colonoscopy (NCD 210.3) covers it once every 24 months for high-risk beneficiaries and once every 10 years for average-risk. A Noridian LCD for outpatient PT covers therapy under specific ICD-10 codes (rotator cuff, OA, post-surgical) but excludes long-term maintenance care after functional plateau.
Common Misconceptions
An LCD only applies to the MAC's jurisdiction — practices in different MAC jurisdictions may face different LCD criteria for the same service. NCDs override LCDs whenever both exist for the same service. 'Medical necessity' for Medicare is defined by the LCD/NCD, not by the practitioner's clinical judgment alone.
Practical Application
Before billing services with frequent denials (PT, advanced imaging, certain injections), pull the relevant LCD or NCD from the CMS Medicare Coverage Database (MCD), confirm the diagnosis code is covered, and document the medical-necessity criteria in the encounter note. CARC 50 (not medically necessary) denials almost always trace back to an LCD/NCD criteria failure.
Related Terms
CMS
CMS is the federal agency within the U.S. Department of Health and Human Services that administers Medicare, jointly administers Medicaid and CHIP with the states, and oversees the Health Insurance Marketplaces and HIPAA administrative simplification.
Read definition arrow_forwardMAC (Medicare Administrative Contractor)
A Medicare Administrative Contractor is a private organization that contracts with CMS to process Medicare Part A and Part B claims (or DME claims) within a defined geographic jurisdiction, applying CMS coverage rules and publishing local coverage determinations.
Read definition arrow_forwardICD-10-CM
ICD-10-CM is the U.S. clinical modification of the WHO's ICD-10 diagnosis code set, maintained by the CDC's National Center for Health Statistics, used to report diagnoses on all HIPAA-covered claims.
Read definition arrow_forwardCARC 50
CARC 50 indicates the payer denied a claim because it determined the services were not medically necessary based on its medical-necessity policy, LCD, NCD, or commercial medical-policy criteria.
Read definition arrow_forwardWhere This Applies on MedPrecision
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