Medicare Coverage Database
Search by keyword, CPT/HCPCS code, ICD-10-CM code, or document ID to locate active and retired NCDs, LCDs, and related articles.
Coverage Policy Resource Center
Medical necessity must be visible.
Use current coverage rules, coding edits, unit limits, and payer instructions before the denial—not after it.
Start here
A correct code can still fail coverage.
Coverage depends on more than whether the service made clinical sense. The payer may also require a covered indication, specific documentation, a frequency limit, prior treatment, authorization, correct code combinations, and defensible units.
These links open the current publisher page. Confirm the date of service, payer, plan, state, MAC, jurisdiction, and provider type before applying any guidance.
Official coverage-policy tools
Find the rule behind the claim.
Use live source pages instead of saved screenshots or old policy PDFs. Coverage documents and edit files change.
Local coverage & billing articles
Confirm the applicable MAC and jurisdiction, then read the LCD together with its linked Billing and Coding Article. The code list may live in the article rather than the LCD.
National coverage decisions
Check whether a national policy controls the service before relying on local guidance. Confirm the policy version and date that apply to the claim.
Procedure-to-Procedure edits
Review current-quarter edit files when services are reported together. A modifier should reflect a supported clinical distinction, not simply bypass an edit.
Medically Unlikely Edits
Check current unit-of-service edits, the adjudication indicator, and the record supporting every unit. Not every code has a published MUE.
Find the correct contractor
Coverage and billing instructions can depend on provider type and jurisdiction. Use the official directory to identify the contractor responsible for the claim.
When Medical Necessity Isn't Enough
Four places a defensible service can still break down.
These examples are educational prompts for internal review. They show where policy, documentation, code relationships, or units can create risk even when the care itself was appropriate.
The treatment may be necessary. The units may still deny.
The record needs the wound location, measurements, tissue treated, total surface area, method, and the facts supporting the units reported. A missing or inconsistent measurement can turn a clinically appropriate service into an unsupported claim.
Dose, units, and waste must tell the same story.
The order, amount administered, discarded amount when applicable, HCPCS unit definition, and claim units must reconcile. Medical necessity alone does not fix a unit conversion or documentation gap.
Separate services need separate support.
When an NCCI edit applies, the record must show why the services were distinct by site, session, encounter, lesion, or other applicable circumstance before an associated modifier is considered.
Frequency rules can outweigh a familiar diagnosis.
A repeat service may require a defined interval, prior-treatment history, progression, test result, or other coverage criterion. Check the current policy before scheduling or billing the next service.
Pre-claim coverage review
Six checks before the claim goes out.
Build this sequence into high-dollar, recurring, newly added, or frequently denied services first.
Identify the service
Confirm the code, units, setting, provider type, and date of service you are evaluating.
Find the controlling policy
Check the NCD first, then the applicable LCD, linked article, and patient-specific payer policy.
Match the patient facts
Verify covered indications, exclusions, frequency limits, prerequisites, and authorization requirements.
Check code relationships
Review current NCCI PTP edits, MUEs, unit definitions, and modifier requirements when applicable.
Read the record as an auditor
Make sure the reason, findings, measurements, failed treatments, plan, and units are visible without assumptions.
Resolve the gap before billing
Route unanswered questions to the appropriate clinical, coding, billing, or compliance owner before the claim leaves the practice.
ARPro educational tool
E/M MDM readiness scorecard
Choose the highest current AMA tier supported by each documented element. The tool applies the two-of-three MDM framework as a cross-check and intentionally stops short of assigning a code.
Choose the highest current AMA tier supported by the conditions actively evaluated or managed today—not the entire problem list.
Choose the highest current AMA tier fully supported by the documented data categories and qualifying work.
Choose the highest current AMA tier supported by the management decisions documented for this encounter.
Do not enter patient information. This tool stores nothing and asks only for general tier selections.
Turn the rule into practice
Teach the team where the denial actually begins.
ARPro Medical connects payer rules to real records, workflow gaps, provider education, and corrective action. The goal is to catch the risk while the practice can still do something about it.
Explore education and webinarsNeed a record-level review?
Find the gap before it becomes a denial or recoupment.
ARPro Medical can review selected records, current coverage guidance, code relationships, units, and recurring denial patterns without replacing your coding or billing team.
Request a compliance snapshot