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Improving Transparency in Medicare

Jan 30, 2019

On January 8, 2019, the Centers for Medicare & Medicaid Services (CMS) implemented substantial changes to their Program Integrity Manual Chapter 13 – Local Coverage Determinations (LCD). The revisions to this chapter were the result of a provision in the 21st Century Cures Act intended to improve transparency in the LCD process. CMS released a Fact Sheet providing an overview of the revisions to the manual. Some of the most significant changes include:

  • Contractor Advisory Committee (CAC) participation is now expanded to more health care professionals. In addition to physicians, nurses, social workers, epidemiologists, beneficiaries, etc., are encouraged to participate in CAC meetings. CAC meetings are now open to the public.
  • Medicare Administrative Contractors (MACs) may now hold meetings that are open to the public, separate from CAC meetings, to present proposed coverage, including evidence and rationale of decisions. MACs will respond to public comments and notify the public when they publish a final decision.
  • There is a new process by which interested parties in a MAC jurisdiction can request a new LCD with an option to request an informal meeting to discuss potential LCD requests. Proposed policies are retired if they are not finalized within 1 year of the original posting date. In addition, the LCD reconsideration process is now consistent with the National Coverage Determination reconsideration process.
  • International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) codes will be removed from future LCDs.

Complete guidance on the new LCD process can be found in Chapter 13 of the Medicare Program Integrity Manual.

Please look out for an article in the April issue of The Physiatrist from AAPM&R member, Dr. Marc E. Duerden, providing a detailed explanation of the new process and the role physiatrists may play.