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CMS COVERAGE DECISIONS: MACs Can Make Exceptions to LCDs

Posted on 22. Sep, 2009 by in Provider News

RACs can make exceptions only to approve claims.

Coders know local coverage decisions are known as Medicare’s “final say. If the LCD makes a statement, you can count on your MAC to never veer from that rule. That’s about to change.

CMS has opened the door to giving MACs some wiggle room in adhering to LCDs. Transmittal 302, issued on Sept. 11, notes that MACs “have the authority to apply an exception to the clinically reasonable and necessary requirements described in an LCD.”

The exceptions must be rare, and the MAC can make them only after thoroughly reviewing a patient’s medical record and analyzing the information.

“Most likely the exceptions to the LCDs would have to be made during the appeal phase,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions. “Thorough review of the patient’s medical record is not...

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