Chapter 22 — Further Reading

As with Chapter 21, nearly everything canonical here is free — the coverage determinations, the articles, the manuals, and the ABN form and instructions are all public CMS documents. The billing and coding article in particular is the single most useful free document most coders have never opened.

Tier 1 — Verified canonical sources

The Medicare Coverage Database, CMS. Free and searchable by code, keyword, state, and contractor. Holds the NCDs, the LCDs, the proposed LCDs, and the billing and coding articles. §22.5's five-step procedure is a description of using this one site.

National coverage determinations, individually. Read the conditions — most that matter are "covered when [criteria] are met," and the criteria are what your documentation must satisfy.

Local coverage determinations and their associated billing and coding articles, for your jurisdiction.

The article is the operational document. It contains the CPT and HCPCS codes the policy applies to, the ICD-10-CM codes that support medical necessity, documentation requirements, and utilization expectations. If you read one thing from this chapter's list, read the article for your highest-volume service.

Proposed LCDs and the response-to-comments documents. The response to comments states what objections were raised and how the contractor answered them — the best available preparation for an appeal, and almost nobody reads it.

The LCD reconsideration process, as published by each contractor. Open to anyone with supporting evidence.

Social Security Act § 1862(a)(1)(A). Free. Two lines, and everything in this chapter rests on them.

Medicare Program Integrity Manual (Publication 100-08), particularly the chapters on coverage determinations, LCD development, and medical review. This is where the machinery is described, and it explains why the documents look the way they do.

Medicare Claims Processing Manual (Publication 100-04), Chapter 30 — financial liability protections, including the ABN. The ABN rules, in the source.

The ABN form (CMS-R-131) and its instructions, CMS. Free. The instructions state the requirements, describe the three options, and address routine and blanket notices explicitly. §22.8 and Case Study 2 are a reading of this document. Anyone who issues ABNs should have read it and most have not.

CMS guidance on the liability modifiers GA, GX, GY, and GZ.

Medicare Benefit Policy Manual (Publication 100-02) for the benefit categories themselves — relevant to distinguishing "not reasonable and necessary" from "not a benefit at all," which is the GY question.

Commercial payer medical policies. Most large payers publish theirs. For a commercial claim these are the operative document, and they perform the LCD-plus-article function.

Payer prior authorization requirements and lists, and their peer-to-peer review procedures and deadlines.

OIG Work Plan and reports on medical necessity, on advance beneficiary notices, and on prior authorization. Both case studies rest on documented patterns.

Tier 2 — Attributed, specifics unverified

AAPC and AHIMA material on medical necessity, LCDs, and ABNs. Both organizations publish substantial free content, and the coded-wrong-versus-never-covered distinction benefits from a second voice.

Specialty society guidance on coverage policies affecting their services. Particularly valuable because societies frequently participate in LCD comment periods and reconsiderations, and they will tell you what has already been argued.

Utilization management and prior authorization literature, including the substantial policy debate about administrative burden. Worth reading for context on why the mechanism exists and what it costs.

Patient advocacy material on ABNs and observation notices. The other side of §22.8, and it will tell you what patients actually understand — which is less than practices assume.

Published analyses of prior authorization denial and overturn rates. Useful for calibrating how often an initial denial is the last word. Treat specific figures as study-specific.

Compliance guidance on ABN processes, including the routine-ABN problem. Case Study 2's subject, and better covered in the compliance literature than in coding training.

Tier 3 — Illustrative and constructed

All examples in §22.1 through §22.7, including the frequency-limitation table.

The referral excerpt in §22.10's 📋 Read the Chart and the entire Account 10-5502 walkthrough in §22.11.

Case Study 1 in its entirety — the practice, the two reschedules, the four drifts, and the months to resolve. Constructed; the mechanism is ordinary.

Case Study 2 in its entirety — the practice, the six years, the pre-printed form, and the family member's letter. Constructed; the routine-ABN problem is addressed explicitly in CMS's own instructions.

Account 10-4471's Q3 and Q5 resolutions, including the constructed post-March-14 imaging.

Three things worth doing

Open the billing and coding article for your highest-volume service and find the diagnosis list. Then compare it to what you actually report. Five minutes, and it will either reassure you or find you something.

Read the ABN instructions and then look at your own form. Does the service line name a service? Does the reason line give a reason specific to a patient? Is there a real estimate? Is the option block blank? Case Study 2 is a practice that never did this.

And find one proposed LCD in your jurisdiction that affects something you bill. Read it, read the comment deadline, and notice that you could comment. Almost nobody in this field knows that door exists, and walking up to it once changes how you think about the rest of the book.