Policy Questions & Answers (Q&As)

WPS Medicare regularly receives feedback regarding locating coverage information. Some of the feedback indicates a misunderstanding about how medical policies function within the Medicare program.

The following Q&As explain why there may not be a Local Coverage Determination (LCD) for a particular procedure code. This information will also help you locate coverage information about procedure codes governed by LCDs.

Q) What is meant when WPS Medicare uses the word "Policy?"
A) WPS Medicare normally uses the word "policy" to refer to Medical Policies explaining coverage criteria for a specific service or procedure. The two types of policies are: Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). We do not typically use the word policy to refer to internal guidelines or protocols.

Q) Why can't I locate a Local Coverage Determination (LCD) for my procedure code?
A) Not all services are governed by LCDs. An LCD is a decision by a Medicare Administrative Contractor (MAC), fiscal intermediary or carrier whether to cover a particular service on a MAC wide, intermediary wide or carrier wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether the service is reasonable and necessary).

LCDs pertain to services or items not addressed in National Coverage Determinations (NCDs) or program manuals. LCDs are primarily developed for the following reasons:

  • To define the appropriate use of new technologies.
  • To address services with an abuse history or potential.
  • High volume, high dollar services.

In the absence of written instructions please be sure to document the medical necessity of a service. (Please see additional Policy Q&As for assistance in locating LCDs for a specific procedure code)

Q) How can I best locate a Local Coverage Determination (LCD) for a specific procedure code?
A) We recommend using our WPS Medicare website

  • Select Policy from the drop down list (just left of the search box).
  • Enter your procedure code in the search box and select "search".
  • Look at the search results for one or more policies pertaining to your procedure code. These will often be listed as a "KeyMatch" and highlighted in yellow. However, you may need to scan the search results as the appropriate policy will not always be listed first.

Note: If you do not receive any matches to your search please re-check what you used in your search (for example, did you correctly type the procedure code, is "Policy" selected from the drop down list) If all the information was correct, then there are no LCDs which relate to your procedure code.

Q) How can I find a procedure code within a Local Coverage Determination (LCD)?
A) You can search for a procedure code within a specific LCD by:

  • Selecting "Edit" and
  • Then "Find on this page" on your web browser toolbar. This is usually located in the upper left corner of your screen. Alternatively, you can press the "CTRL" and "F" keys on your keyboard. Either method will open a search box where you can enter your procedure code.
  • If you use Microsoft Internet Explorer 8.0 the program will highlight each occurrence of the procedure code in yellow. If you use Microsoft Internet Explorer 7.0 you will need to select search to highlight the occurrences one at a time, starting with the first entry.

Page Last Updated: Wednesday, 14-Dec-2011 10:30:37 CST