Coverage: LCD, NCD and Billing & Coding Articles

Bundling asks whether two codes may be billed together. Coverage asks a different question: is this service payable for this diagnosis, in this state, on this date? That is medical necessity, and it is decided by a different set of documents.

NCD

Issued by CMS and binding nationally. Where one exists it settles the question, and no state narrowing applies to it.

LCD

Issued by a Medicare Administrative Contractor, binding only in its jurisdiction. It carries the reasoning — indications, limitations and what the contractor considers reasonable and necessary.

Billing & Coding Article

Paired to an LCD, and where the code lists actually live. The great majority of LCDs carry no ICD-10 list at all — the article is the document an edit is built from.

Look up a code

Add a diagnosis to test it against the covered and non-covered lists. Add a state to narrow to the contractor that would adjudicate the claim — the same procedure can be payable in one state and denied in the next.

Try:

Coverage is contractor-specific: the same procedure can be payable in one state and denied in the next. Add a diagnosis to test whether it appears on the covered list for the policies that govern this code.

One state can have more than one contractor

A state is not served by a single Medicare contractor. Professional and outpatient claims, home health and hospice, and DMEPOS each go to a different one, and each publishes its own policies. So a search narrowed to a state can legitimately return two policies that disagree — they govern different claim populations rather than contradicting each other. Resolving coverage means identifying the contractor that adjudicates your claim type, then reading its policy in force on the date of service.

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