Amanda Whitener has extensive revenue cycle expertise dating back nearly a decade ranging from ambulatory surgery centers to optometry. As VisionWeb's RCM Account Manager, she focuses on helping ODs experience financial freedom by ensuring claims are worked quickly and correctly as she has robust knowledge of operations for various areas of the practice. Currently, Amanda's primary role is helping offices reduce billing burden and labor costs while maximizing cash coming through the door.
Moving to a more medical model of practicing can seem like drinking water from a firehose! With such a copious number of rules and regulations to follow, sometimes providers feel it is not a great option for their practice; however, it can be very lucrative. Let’s take a moment to explore a few question/answer scenarios as it relates to billing to Medicare.
Question #1: What is a Medicare MAC?
Answer: MAC stands for Medicare Administrative Contractor. There are 7 unique Medicare contractors with 12 unique jurisdictions. The MAC acts as a processor for Medicare claims in their specific jurisdiction and is the main contact between Medicare fee-for-service and enrolled healthcare providers. Essentially, they are the vehicle of communication between CMS and providers. They also set and enforce LCDs and NCDs.
Question #2: What is an NCD, and how is it different from an LCD?
Answer: An NCD, or national coverage determination, is essentially a guideline set by CMS to answer the question of whether a procedure or item should be covered by Medicare. For example, an NCD may indicate a certain procedure is not payable if CMS deems it experimental. If so, all MACs are advised to follow that decision when processing claims. An LCD, or local coverage determination, on the other hand, is a guideline set by a particular MAC. These may be implemented if CMS has not yet made a ruling on a procedure.
Both NCDs and LCDs help determine the DXs that denote the medical necessity of a particular procedure and whether it is reimbursable or not. They also indicate the MUEs, or medically unlikely edits, of a particular procedure. In other words, they outline the acceptable frequency of a specific procedure, i.e.: once a year, twice a year, etc.
Question #3: Is my MAC required to follow all LCDs?
Answer: Each MAC follows their own LCDs and is not required to follow other MAC’s LCDs, but all jurisdictions are required to follow the NCDs. Use your resources to determine if a procedure is covered before billing Medicare. In the event that a procedure does not have an LCD or NCD and it is unclear whether Medicare will cover it or not, an ABN might be appropriate.
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