NCDs and LCDs Convert to ICD-10

on Monday, 12 October 2015. All News Items | Outpatient Services | Medicare Coverage | Coding | Billing

Out With the Old, In With the New

We are now two weeks (14 days) into the conversion to ICD-10. Hopefully for your hospital the transition has been as smooth as possible and the inevitable issues of such a huge change are settling down. But having lived through change before, we all realize that issues will continue to come up for weeks and months. One such potential issue is with Medicare coverage policies – National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

Our usual article on the second week of the month lists new, retired and draft policies from each Medicare Administrative Contractor (MAC). You will not see that this month because all of the previously active policies from prior to October 1st were retired and new LCDs and Articles were made active to accommodate the change to ICD-10. The intent with these new policies was not to change the coverage requirements for any service, but to simply transition to I-10 codes. However, the conversion from I-9 to I-10 is not always as straight forward as it may seem and there is a chance that all the diagnoses covered in the retired I-9 policies may not have been appropriately forwarded to the new policies.

It would be particularly difficult for providers to read through each newly active policy and identify if any codes are missing. So what are providers to do to assure their services continue to be covered as before? Here are a few suggestions to address the transition of coverage policies.

  1. If there was a diagnosis, especially if it was an unspecified code, that you know supported medical necessity for a particular test frequently, look at the new policy and verify if the ICD-10 equivalent code is included.
  2. Make sure front end systems and pre-billing edits are up to date with the new ICD-10 coverage diagnoses, so that claims are halted for lack of medical necessity prior to submission. Have processes in place to investigate and address claims failing for lack of a covered diagnosis.
  3. Track your medical necessity denials by procedure code, by volume. If a procedure has an increased volume of denials after October 1st, determine the reason for the denial and make sure it is not related to a change in the policy requirements for diagnosis codes.

**If your internal systems are not capable of collecting this information, you may be interested in MMP’s Outpatient HIQUP (Hospital Improvement in Quality and Performance) report which analyses your monthly Medicare remittances and provides information on potential billing issues and denials, such as the volume of medical necessity denials by procedure code. Please contact MMP or visit our website ( for more information on our HIQUP report under the Products tab.

  1. If you discover an issue with a coverage policy where a diagnosis was covered pre-I-10, but is not now, address the issue with your MAC. MAC websites include instructions on how to request a Reconsideration of an LCD or Article. Use this process to request a code addition.

You can view all the newly active LCDs and Articles on your MAC’s website or on the Medicare Coverage Database. We are going to list new draft policies for all the MACs this month and also want to make you aware of a new NCD for coverage of Screening for Colorectal Cancer using CologuardTM.

CMS has determined that the evidence is sufficient to cover Cologuard™ - a multitarget stool DNA test – as a colorectal cancer screening test -

  • Effective for dates of service on and after October 9, 2014
  • For beneficiaries
    • Age 50 to 85 years
    • Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test); and
    • At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).
  • Covered once every 3 years
  • No coinsurance or deductible
  • Performed by a laboratory authorized by the manufacturer to perform the Cologuard™ test
  • Reported with HCPCS code G0464 (Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (for example, KRAS, NDRG4 and BMP3))
  • Covered when reported on types of bill 13x, 14x, or 85x
  • Requires diagnosis codes Z12.12 and Z12.11 for coverage

If you need more information about ICD-10 updates for NCD see the Medicare Coverage ICD-10 Information webpage. So out with the old and in with the new. It is keeping up with the new that is the challenge.

New draft LCDs from the previous month include:


Cahaba JJ

IDTitleComment Start DateComment End DateFinalStatus
DL36444 Pathology and Laboratory: Molecular RBC Phenotype 11/6/2015 12/22/2015 No Draft
DL36446 Pathology and Laboratory: Partial Genome Profiling in Non Small Cell Lung Cancer (NSCLC) 11/6/2015 12/22/2015 No Draft



IDTitleComment Start DateComment End DateFinalStatus
DL36485 MolDX: HLA-DQB1*06:02 Testing for Narcolepsy 10/21/2015 12/07/2015 No Draft
DL36487 MolDX: Chromosome 1p/19q deletion analysis 10/21/2015 12/07/2015 No Draft
DL36460 Bone Mass Measurement 10/21/2015 12/07/2015 No Draft
DL36456 MolDX: BRCA1 and BRCA2 Genetic Testing 10/21/2015 12/07/2015 No Draft
DL36425 MolDX: Breast Cancer Assay: Prosigna 10/21/2015 12/07/2015 No Draft
DL36458 MolDX: Breast Cancer IndexSM Genetic Assay 10/21/2015 12/07/2015 No Draft
DL36469 Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder 10/21/2015 12/07/2015 No Draft


First Coast JN

IDTitleComment Start DateComment End DateFinalStatus
DL36499 BRCA1 and BRCA2 Genetic Testing 10/8/2015 11/22/2015 No Draft
DL36504 Hyperbaric Oxygen (HBO) Therapy 10/8/2015 11/22/2015 No Draft
DL36342 Screening and Diagnostic Mammography 10/8/2015 11/22/2015 No Draft
DL33771 Vitamin D; 25 hydroxy, includes fraction(s), if performed 10/8/2015 11/22/2015 No Draft


NGS J6 and JK

IDTitleComment Start DateComment End DateFinalStatus
DL33614 Debridement Services 10/29/2015 12/12/2015 No Draft
DL33394 Drugs and Biologicals, Coverage of, for Label and Off-Label Uses 10/29/2015 12/12/2015 No Draft
DL36376 Genomic Sequence Analysis Panels in the Treatment of Non-Small Cell Lung Cancer 10/29/2015 12/12/2015 No Draft
DL36406 Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint 10/29/2015 12/12/2015 No Draft
DL35000 Molecular Pathology Procedures 10/29/2015 12/12/2015 No Draft
DL35076 Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 10/29/2015 12/12/2015 No Draft


Noridian JE

No updates this month


Noridian JF

No updates this month


Novitas JH and JL

IDTitleComment Start DateComment End DateFinalStatus
DL35395 Autonomic Function Tests 9/17/2015 11/05/2015 No Draft
DL34856 C-Reactive Protein High Sensitivity Testing (hsCRP) 9/17/2015 11/05/2015 No Draft
DL34974 Facet Joint Injections 9/17/2015 11/05/2015 No Draft
DL35099 Frequency of Laboratory Tests 9/17/2015 11/05/2015 No Draft
DL36434 Microvascular Therapy 9/17/2015 11/05/2015 No Draft
DL35033 Nerve Blockade for Treatment of Chronic Pain and Neuropathy 9/17/2015 11/05/2015 No Draft
DL34975 Neurophysiology Evoked Potentials (NEPs) 9/17/2015 11/05/2015 No Draft
DL36419 Outpatient Wireless Pulmonary Artery Pressure Monitoring for Heart Failure 9/17/2015 11/05/2015 No Draft
DL34938 Removal of Benign Skin Lesions 9/17/2015 11/05/2015 No Draft
DL36423 Strapping 9/17/2015 11/05/2015 No Draft
DL35036 Therapy and Rehabilitation Services (PT, OT) 9/17/2015 11/05/2015 No Draft


Palmetto JM

IDTitleComment Start DateComment End DateFinalStatus
DL36483 MolDX: Chromosome 1p/19q deletion analysis 10/13/2015 11/27/2015 No Draft
DL36466 Application of Skin Substitutes 10/13/2015 11/27/2015 No Draft
DL34415 CT of the Abdomen and Pelvis 10/13/2015 11/27/2015 No Draft
DL36471 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy 10/13/2015 11/27/2015 No Draft
DL36082 MolDX: BRCA1 and BRCA2 Genetic Testing 10/13/2015 11/27/2015 No Draft
DL36125 MolDX: Breast Cancer Assay: Prosigna 10/13/2015 11/27/2015 No Draft
DL34429 Outpatient Speech Language Pathology 10/13/2015 11/27/2015 No Draft
DL34434 Upper Gastrointestinal Endoscopy and Visualization 10/13/2015 11/27/2015 No Draft
DL36427 Wireless Capsule Endoscopy 10/13/2015 11/27/2015 No Draft


WPS J5 and J8

No updates this month


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is 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. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

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.

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