Product A

LCD and NCD Editing

Product A now supports Local Coverage Determination (LCD) and National Coverage Determination (NCD)
editing for your claims processing needs. LCD/NCD editing is separately licensed and additional fees apply
to use this feature.

Here we highlight some things to know about LCD/NCD edits in Product A.

About the Policies

LCD and NCD are two rulings delineating Medicare coverage for specific medical services and procedures.
Both determinations establish policies specific to an item or service.

LCD Policy—Determines Medicare medical necessity coverage for specific services, medical procedures,
and devices on a local level. LCDs are established by each Medicare Administrative Contractor (MAC) for
their specific jurisdiction(s) and are determined according to the claim's NPI/CCN or billing ZIP code.
NCD Policy—Determines Medicare coverage for specific services, medical procedures, and devices on a
national level. NCDs are established by CMS and apply to all Medicare claims. All MACs are obligated to
follow NCD rulings.

FAQs
By partnering with MediQuant®, we offer over 5,000 LCD/NCD edits that cover an array of policies involving
age, sex, diagnoses, units, covered procedures, etc. Here we answer some questions you may have about
these edits:

Are the LCD/NCD edits activated by default?

All LCD/NCD edits are deactivated (turned off) by default when you create a configuration. You must
manually activate the LCD/NCD edits in new and existing reimbursement configurations if you wish to use
them. You can activate or deactivate these edits individually or all at one time.

What provider types can LCD/NCD edits be activated/deactivated for?

Policy and MAC coverages are applicable to provider types as follows:

Medicare Part A/B: Acute Inpatient, ASC, ESRD, FQHC, Hospital Outpatient, LTCH, IPF, IRF,
Professional, and SNF

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
1
 Medicare Part A applies to institutional billing with a UB-04 claim type.
Medicare Part B applies to professional billing with a CMS-1500 claim type.
DME MACs: Suppliers
HHH MACs: Home Health and Hospice

What can I do with these edits?

If you need to modify your edits to deviate from standard policies, you can set up LCD/NCD edits in many
of the same ways as Product A stock edits. Here are some examples:

Customize them by creating edit exceptions (if you license exceptions).

Include or exclude LCD/NCD policies in configuration reports.
Map the edit dispositions and/or messages to your claim adjudication messages.
Monitor edits instead of running them (if you license real-time analytics).
Override default dispositions.

How do these edits differ from stock edits in Product A?

Unlike most stock edits, LCD/NCD edits have three default dispositions that can trigger depending on
whether the policy conditions are met on the claim: Information, Line Rejection, and Pend for Review.

If a claim meets the conditions for an LCD/NCD policy, the appropriate edit triggers with an Information or
Pend for Review disposition.
If a claim does not meet policy conditions, the appropriate edit triggers with a Line Rejection disposition.

LCD/NCD edits also have up to 11 different messages. When an LCD/NCD edit triggers on a claim, the edit
ID is pipe-delimited and followed by a letter (A through K) to indicate which of the 11 messages apply based
on the policy type. For more information, see Working with Policy Types.

Additionally, when LCD/NCD edits trigger on a claim, you can access the policy documentation in PDF form
in place of an edit message whenever an LCD/NCD edit triggers. To view the policy, click the policy ID in the
edit results.

What if I want to find an edit specific to an LCD/NCD policy?

The edit ID and edit name in Burgess Source are derived from the policy ID and policy name, respectively. For
example, LCD policy A52953 (Chemotherapy Administration) has edit ID A52953 and edit name
Chemotherapy Administration.

If a service or policy falls under both NCD and LCD, then the NCD edit should take precedence, but both
policies should be referenced. If there is not an NCD appropriate for the bill, then the correct reference would
be the LCD.

How often are the policies updated?

LCD/NCD edits are based on policies created by MACs and CMS, and we update the LCD/NCD policies,
CPT® codes, and ICD data monthly. This includes adding new edits, marking edits that are past the effective
date, and updating the policy documents accordingly.

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
2
Whenever the policies are updated, we provide you with a MediQuant Change Documentation PDF, which
you can access through our online release notes.

What happens if a policy is no longer in effect?

Just like many of our stock edits, LCD/NCD edits have effective end dates for when the policy is no longer
applicable. For example, policy A54363 (MolDX: AlloMap Billing and Coding Guidelines) has an end date of
11/1/2019. This means that this edit no longer applies to services with a date of service after 11/1/2019.

When edits are past their effective end date, a warning icon appears next to the edit ID (see Edit
Walkthrough below). You can find the effective end date when you turn on an LCD/NCD edit in a configuration
and click the edit ID. The date appears under the edit name.

What happens when a specific claim service or issue applies to both LCD and NCD policies?
When a specific service or issue on a claim is covered by both an LCD and NCD policy, Product A returns
both edits.

Edit Walkthrough
You can find the LCD/NCD edits in Product A under Design > Configurations > [Select Configuration]
> Edits Only > MediQuant. Here's a look at a sample view of the edits with some key elements highlighted.
The table that follows provides a description of each element, listed alphabetically.

Edit Elements
Element Description

Default Shows the three default dispositions:

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
3
 Element Description

Disposition Information—Provides details about why the edit may have triggered and/or why the
policy conditions were met.
Line Rejection—Rejects a claim line that does not meet the policy conditions.
Pend for Review—Holds the claim for manual review (doesn't pay).

Edit ID Reflects the ID of the edit, which is also the LCD/NCD policy ID.

LCD edit IDs start with A or L

NCD edit IDs start with N or other values other than A and L
LCD/NCD edits end in letters A through K, when applicable, depending on the policy
type.

Edit Name Reflects the name of the edit, which is also the LCD/NCD policy name.

Edit Toggle Lets you activate, deactivate, or monitor edits.

Expand Icon Provides information about the policy. To view the policy document, click the Expand
icon and then the link Click here to view PDF document.

Past Policy Indicates a policy that is past its effective date.

Effective Date
Icon

Viewing LCD Jurisdictions
In order to determine if an LCD policy applies to a billed claim, Product A first determines if the claim is Part
A or Part B. The LCD feature includes an interactive map and grid that displays the LCD jurisdictions for
the current year. When you click a specific jurisdiction, Burgess Source provides the following details for
the specified jurisdiction:

Name of the jurisdiction

States under the jurisdiction
Number of active edits and total edits for both Medicare Part A and B

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
4
To view the LCD jurisdiction map:

1. Navigate to Design > Configurations, select the desired configuration, and click Edits Only from the top
right.
2. Hover over the MediQuant edit origin card and click LCD A/B, LCD HHH, or LCD DME.
3. At the top right, click the Map icon (it will appear red if you already have it selected). Hover over
different areas on the map to see information for each jurisdiction, including active and customized edits.
Alternatively, select the Grid View icon at the top right to view this information in a list format.

Working with Policy Types

LCD/NCD edits can have up to 11 different possible messages, which are categorized by policy type. These
policy types are distinguished by letters A through K. The table below lists the different policy types as well as
their associated messages and dispositions. (Depending on the monthly MediQuant data updates, all 11
policy types may not apply to some edits.)

Note: The {0} variable in the message represents the edit/policy ID.

Policy Types
Policy Type Default
Message
Type Description Disposition

A Coverage Policy {0} indicates that this procedure is only covered when the Line
Dependent patient’s age is between {1} and {2} years. This patient’s age is {3}. Rejection
on Age

B Coverage Policy {0} indicates that this procedure is only covered when the Line

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
5
 Policy Type Default
Message
Type Description Disposition

Dependent patient’s sex is {1}. Rejection

on Sex

C Coverage Policy {0} indicates that this procedure is not covered when the Line
Denied for patient’s age is between {1} and {2} years. This patient’s age is {3}. Rejection
Age

D Coverage Policy {0} indicates that this procedure is not covered due to the Line
Denied for patient’s sex. Rejection
Sex

E Coverage Policy {0} indicates that this procedure is always denied coverage. Line
Always Rejection
Denied

F Maximum Policy {0} indicates that this procedure is limited to billing {1} units Line
Frequency every {2} {3}. See claim ID {4} for additional units billed for this Rejection
Exceeded procedure on this date of service.

G Secondary Policy {0} requires certain diagnoses to be billed for this procedure Line
Diagnosis code. While diagnosis {1} is billed on the claim, a second diagnosis is Rejection
Required also required. Policy {0} requires certain diagnoses to be billed for this
procedure code. While diagnoses {1} are billed on the claim, a second
diagnosis is also required.

H Diagnosis Policy {0} requires a certain diagnosis to be billed for this procedure Line
Required code. Rejection

I Coverage Policy {0} indicates that this procedure is covered unless certain Line
Denied for diagnoses are present. This procedure is not covered because Rejection
Diagnosis diagnosis {1} is billed. Policy {0} indicates that this procedure is
covered unless certain diagnoses are present. This procedure is not
covered because diagnoses {1} are billed.

J Medical Policy {0} indicates that medical necessity criteria apply to this Pend for
Necessity procedure. The claim should be reviewed. For more information, see Review
Review policy documentation.
Required

K Medical Policy {0} indicates that this procedure meets medical necessity Information
Necessity coverage requirements. For more information, see policy
Criteria Met documentation.

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
6
Applying Configuration- and Policy-Level Changes
You can set up disposition overrides, exceptions (if licensed), and message mapping for these policy types,
similar to how you can utilize these functions with stock edits. You can apply these changes for policy types
on two different levels to meet your needs:

Note: When viewing policy types in Product A, you will also see an asterisk (*) option, which
allows you to apply your changes to all policy types (A through K).

Configuration level—Apply changes to all policy types or a specific policy type across all LCD/NCD edits.
Specific policy type changes take precedence over "all policy type" changes.
For example:
If you set up a disposition override of User Information for all policy types, all LCD/NCD edits that
trigger on a claim will have a disposition of User Information.
If you set up a disposition override of User Pend for Review for the K policy type, any LCD/NCD
edits that apply to the K policy type will trigger with User Pend for Review.
If you set up both scenarios above, any LCD/NCD edits that apply to the K policy type will trigger
with User Pend for Review, while all other LCD/NCD edits will trigger with User Information.
Policy level—Apply changes to all policy types or a specific policy type for a specific LCD/NCD edit (e.g.,
L34993).
Specific policy type changes take precedence over "all policy type" changes. Furthermore, policy-level
changes take precedence over configuration-level changes (see above).
For example:
If you set up a disposition override of User Information for all policy types for edit L34993, edit
L34993 will always trigger with User Information.
If you set up a disposition override of User Pend for Review for the K policy type for edit L34993,
edit L34993 will trigger with User Pend for Review when the K policy type applies.
If you set up both scenarios above, edit L34993 will trigger with User Pend for Review for the K
policy type, while all other instances of edit L34993 will trigger with User Information.

The screenshot below illustrates elements related to policy types at the policy level:

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
7
To apply changes at the configuration level:

1. Click to view a configuration and click Edits Only from the top right.
2. On the MediQuant edit origin card, click the More Options list icon and select Modify All MediQuant
Policies.
3. When the Modify All LCD/NCD Policies panel appears, the Disposition Override tab displays by default.
Select the tab based on the change you want to make: Disposition Override, Exceptions, or Message
Mapping.
4. Select the policy type (A through K) that you want to modify. Alternatively, select the asterisk * to apply
your changes to all policy types.
5. Make your desired changes as applicable to the tab you selected.
6. Click OK to save your changes and exit the panel. Note that Global Overrides now shows on the
MediQuant card to indicate that you've made global-level changes.

To apply changes at the policy level:

1. Click to view a configuration and click Edits Only from the top right.
2. Search for the desired MediQuant edit by using the Filter Edits search bar or clicking the MediQuant edit
origin card.
3. When you've located your desired edit, click the edit toggle to activate the edit .
4. When the Modify Policy panel appears, the Disposition Override tab displays by default. Select the tab
based on the change you want to make: Disposition Override, Exceptions, or Message Mapping.
5. Select the policy type (A through K) that you want to modify. Alternatively, select the asterisk * to apply
your changes to all policy types.
6. Make your desired changes as applicable to the tab you selected.
7. Click OK to save your changes and exit the panel.

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
8
Mapping Messages
Message mapping for policy types is similar to message mapping for stock edits in Product A. Some key
differences to note are as follows:

Message mapping within a configuration (Message Mapping tab):

When you select the * option for the policy type (which indicates "all" policy types), the Default icon
appears next to all three dispositions for Information, Line Rejection, and Pend for Review.
When you select A through K, only one default disposition appears as applicable to the policy type you
select.
Message mapping under Design > Edit Dispositions > Edit Level:
When mapping messages for a specific LCD/NCD edit, you can click Add Edits and search for the
desired edit by using the search bar or clicking the MediQuant card. When the search results appear,
note that most edit IDs are shown as pipe-delimited followed by a policy type (e.g., A52800|B). If you
select an edit ID without the pipe and policy type, the message mapping you set up will apply to all
policy types.
In addition to the configuration- and policy-level changes we describe in the previous section, you can
apply global-level message mapping for LCD/NCD edits. On the Edit Level tab, when you click Add
Edits and hover over the MediQuant card, you'll see an All LCD/NCD Policies option. This allows you
to apply message mapping to all policy types or a specific policy type for all LCD/NCD edits across all
configurations.

Company A, Sensitive, and Proprietary. © 2021 All rights reserved. Company A is registered with the U.S. Patent and
Trademark Office. CPT copyright 2020 American Medical Association. All rights reserved.
9