LCDs and Claims Submission Reminders
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August 1, 2016

LCDs and Claims Submission Reminders

Local Coverage Determinatons (LCDs) are available to you to help with questions you may have concerning coverage and/or denials you may receive. Our LCDs are continuously reviewed to ensure they are updated with current information; our processing systems are updated to coincide with our policies.

We have seen an increase in inquiries regarding services that have established LCDs. Our Part A Medical Review department would like to remind you to review the Medical Policy section of the CGS website to see if the services you perform have an established LCD to reference for guidance.

Please use the links below to review our current policies.

In addition, please review the following claim submission reminders:

  • If billing an unlisted code, please include the description of the service/lab in the comment/narrative field (Loop 2300 NTE 01). If we need additional information to process the service we may send you an additional documentation request (ADR) letter.
  • When biling Molecular Pathology Tier 2 CPT codes 81400-81408, we request that you list the test that was performed for these codes in Loop 2300 NTE 01, as there are numerous tests included for each code in this group. This will allow us to adjudicate your claim promptly and correctly. If this information is not submitted with your claim, we will send an ADR letter. If the information is not sent upon request, the service will be denied.
  • According to the Mohs Micrographic Surgery LCD L34195, claims submitted with CPT codes 17311 - 17315 (performed on the trunk or extremities) that do not include one or more of the qualifying terms listed under "Indications and Limitations of Coverage" in the comment/narrative field (Loop 2300 NTE 01) may cause processing delays (an ADR will be sent requesting the information) or an incorrect denial. If the information is not received upon request, the service will be denied. Providing this information with your claim will allow CGS to adjudicate your claim promptly and efficiently.
  • Category III CPT codes that are not approved in a National Coverage Determination (NCD) or listed in the supplemental coverage article for LCD L34370 Category III CPT Codesare considered not medically necessary unless they are part of an approved IDE or clinical trial, in which case the appropriate modifier and IDE or trial number must be included on the claim.

If you have any questions on our local policies please reach out to us through the CMD.Inquiry@cgsadmin.com mailbox.


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