February 2004 Newsletter

Cleaner Claims

By: Kathy Novak, Vice President, Partner

LMRPs Get New Name and Format

Over the next two years Medicare carriers and fiscal intermediaries must convert existing Local Medical Review Policies (LMRPs) to Local Coverage Determinations (LCD). The term LCD was first created in the Benefits Improvement and Protection Act (BIPA) section 522. The Centers for Medicare & Medicaid Services (CMS) published the final rule on November 7, 2003 which established that beginning December 8, 2003, local policies are referred to as "Local Coverage Determinations" (LCDs).

An LCD is a decision by a fiscal intermediary or carrier to cover a particular service based on whether the service is reasonable and necessary. The main difference between LMRPs and LCDs is that LCDs contain only the "reasonable and necessary" information, while LMRPs may also contain benefit category or statutory exclusion provisions. When LMRPs are converted to LCDs or new LCDs are developed, any non-reasonable and necessary language must now be communicated to providers through an article.

LMRPs, LCDs and supplemental articles can be found on the Medicare Coverage Database or on your local carrier's or intermediary's website.