NOTE: All in-article links open in a new tab.

Decisions, Determinations, Memos - I'm So Confused!

Published on 

Tuesday, December 10, 2013

 | Medicare Coverage 

Do you know the difference between a National Coverage Determination (NCD) and a Coverage Decision Memorandum? And most importantly, which is binding on Medicare contractors and therefore on providers?

This is addressed in the Medicare Program Integrity Manual, Chapter 13, section 13.1.1:

National Coverage Determinations (NCDs) are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an item or service is considered to be covered (or not covered). Once published in a CMS program instruction, an NCD is binding on all Medicare Administrative Contractors (MACs), Quality Improvement Organizations (QIOs), Program Safeguard Contractors (PSCs) (now known as ZPICs) and beginning 10/1/01 are binding for Medicare+Choice organizations.

“CMS prepares a decision memorandum before preparing the national coverage decision. The decision memorandum is posted on the CMS Web site, that tells interested parties that CMS has concluded its analysis, describes the clinical position, which CMS intends to implement, and provides background on how CMS reached that stance. Coverage Decision Memos are not binding on contractors or ALJs. … The decision outlined in the Coverage Decision Memo will be implemented in a CMS-issued program instruction within 180 days of the end of the calendar quarter in which the memo was posted on the Web site.”

This month, I would like to point out a revision to the Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, NCD 100.1. Effective for dates of service on and after September 24, 2013, facility certification will no longer be required for coverage of covered bariatric surgery procedures. A complete discussion of the policy revisions can be found at MLN Matters Article MM8484.

There is also an interesting Decision Memorandum that was published August 13, 2013 concerning coverage of Cardiac Pacemakers. The memo combines the covered indications (documented non-reversible symptomatic bradycardia) for both single and dual chamber pacemakers. Remember however, that as stated above this decision is not binding until it is published as a CMS program instruction updating the NCD manual. We will provide additional information when this occurs.

Polices and articles can be viewed on the Medicare Coverage Database by entering the policy number in the Document ID search.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.