The Importance of Verifying Regulatory Guidance

by  Jessica Franzese, CPC CPMA
Mar 11th, 2016 - Reviewed/Updated Aug 16th

In the world of medical documentation, things are constantly changing. As medical coding and auditing professionals, we know that CPT and ICD-10 CM codes change annually. We are quick to keep up with these changes, ensuring such things as software updates and the purchase of new manuals. But are we as quick to think of the regulatory guidance changes? Do you know where to look for these changes, or how often changes are made?

When looking at a specific service, we look to Current Procedural Terminology (CPT) for coding guidance. It is important to remember to look at the regulatory guidance as well. The regulatory guidance provides coverage details for tests and procedures that goes above and beyond CPT coding guidance. Regulatory guidance and carrier policy includes such things as allowed (or disallowed) diagnosis codes, diagnosis code sequencing instructions, frequency limitations, and other carrier specific requirements.

National Coverage Determinations (NCDs) are created by the Centers for Medicare and Medicaid Services (CMS). They provide broad based instruction on a particular service for use nationwide. Local Coverage Determinations (LCDs) are created by Medicare Administrative Contractors (MACs) and give instruction specific to the region they have jurisdiction over. LCDs are generally created in the absence of an NCD or to supplement an existing NCD.

There are currently twelve private healthcare companies who have been awarded contracts as a MAC. The MACs do everything from process Medicate Part A and Part B claims to establishing LCDs. The location of your organization determines the MAC for jurisdiction for your area. For example, organizations in Tennessee are covered by Cahaba Government Benefit Administrators, while organizations in Florida are covered by First Coast Service Operations. Unlike CPT and ICD-10CM code changes, NCDs and LCDs can change quarterly.

Because of this, it is vital to visit the website for your regional MAC regularly to ensure you are receiving the most up to date information.

This is a brief synopsis of regulatory guidelines, but I hope this gives you a good starting place. When developing internal policies, or looking for specific coding guidance and instruction for your organization, remember to look beyond CPT and ICD10 CM codes and fully research the national and regional instructions as well. This is the best way to ensure proper claims submission and maximize organizational revenue.