American Academy of Professional Coders (AAPC) Practice Exam

If a National Coverage Determination (NCD) does not exist, what should Medicare contractors do?

1. Automatically deny claims for the item or service

2. Consult with CMS and then make a coverage decision

3. Always approve the claims under state law

4. Follow the manufacturer’s recommendations for the item or service

The correct answer is: Consult with CMS and then make a coverage decision

When a National Coverage Determination (NCD) is not in place, Medicare contractors have the responsibility to gather information and make coverage decisions on a case-by-case basis. This process involves consulting with the Centers for Medicare & Medicaid Services (CMS), which provides guidelines and policies regarding Medicare coverage. The consultation allows Medicare contractors to determine whether there is sufficient evidence to support coverage of the item or service in question based on the patient's specific circumstances and the medical necessity established by guidelines. This approach ensures that decisions are made based on the most relevant and updated information, allowing for a more tailored and appropriate determination regarding coverage for particular items or services. The other options do not align with the standard operating procedures when an NCD is absent. Automatically denying claims or approving them based solely on state law would not take into account the specific needs and circumstances of individual cases, and following manufacturer recommendations does not necessarily mean that a service or item meets Medicare's coverage criteria. Therefore, consulting with CMS as part of the decision-making process is the most accurate and responsible course of action.