6 Things to Consider When Performing a Coverage Analysis

Developing a coverage analysis (CA) can be a very tricky task, especially for a novice analyst. Nonetheless, it is crucial to conduct CAs in order to ensure billing compliance. There are several important items that need to be considered while building a CA. This list is not meant to focus on every single one of these items, but to highlight a few important items that should be considered while building a CA. These items include:

  1. Item or service not part of the schedule of assessments – This could be anything from a biopsy to a scan modality. It is important to read through the entire protocol, rather than relying explicitly on the schedule of assessments. These items can be found in the body of the protocol, visit descriptions (if available), or in the footnotes section.
  2. Frequency of an item or service – Once again, the schedule of assessments may not highlight the exact time points, and there could be items that are being done as clinically indicated or are performed outside the schedule of assessments. Items such as labs may be performed multiple times during a single visit, and the frequency of these items should be considered before making them billable. Additionally, it is necessary to confirm that the frequency at which items are performed is not limited by national or local coverage determinations. Inclusion and appropriate analysis of such items is necessary for an accurate CA.
  3. National and Local Coverage Determinations (NCDs / LCDs) – NCDs apply to coverage throughout the country, while LCDs are based on the state-assigned Medicare Contractor. Consequently, certain items or services may be billable in one state but non-billable in another. It should be noted that NCDs and LCDs never contradict each other, and in some cases, an LCD may provide more coverage information in addition to what the NCD states. Checking the CPT codes for NCDs and LCDs on a platform such as Optum is recommended.
  4. Local vs Central labs – Several studies have labs being conducted at a local and/or central lab. Local labs need to be analyzed as they are performed at the institution. However, central labs are not billable as they are being sent to a central lab for analysis and will not be submitted to Medicare/insurance for reimbursement. Differentiating and accounting for such items is crucial for the accuracy of the CA.
  5. Drugs – Factors that dictate the use of drugs need to be taken into consideration when performing a CA. Drugs administered to patients in an inpatient setting are generally covered, however drugs administered to patients in an outpatient setting have several limitations that should be considered. These limitations need to be addressed on a case-by-case basis. Chapter 4 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual may offer additional insight on this topic.
  6. Most recent citations and updated supporting documents – A CA often relies on supporting guidelines, NCDs, and LCDs. It is important to use guidelines published by a reputable source such as the American Medical Association. It should be noted that only United States-based associations and organizations are referenced, as Medicare may not recognize such references from other countries that utilize different medical practices and coverage policies. Furthermore, these documents are updated on a regular basis, so citing the most recent version and saving a copy of it for future reference is also recommended.