What Is an LCD in Wound Care? Local Coverage Determinations Explained
LCDs in wound care explained — what Local Coverage Determinations are, which MACs issue them, the three primary wound care LCDs, and why they determine whether your claims get paid.
Damon Ebanks
Medipyxis
What Is an LCD in Wound Care?
A Local Coverage Determination (LCD) is a coverage policy issued by a Medicare Administrative Contractor (MAC) that defines when a service is considered medically necessary within that MAC's jurisdiction. In wound care, LCDs govern which wound types qualify for advanced treatments like skin substitutes, which diagnoses support billing, what documentation must appear in the record, and how frequently a service can be performed.
LCDs are enforceable coverage criteria, not guidelines. A claim that fails to meet LCD requirements will be denied regardless of clinical appropriateness.
How is an LCD different from an NCD?
A National Coverage Determination (NCD) is issued by CMS centrally and applies uniformly nationwide. An LCD is issued by an individual MAC and applies only within that MAC's territory. When an NCD exists, it takes precedence; when none exists, the MAC fills the gap with an LCD.
Most wound care services -- debridement, skin substitute application, negative pressure wound therapy -- have no NCD. Coverage is determined entirely through LCDs. The same procedure on the same wound type can be covered in one jurisdiction and denied in another, and a multi-state practice must comply with each MAC's LCD independently.
What are the three primary wound care LCDs?
Three LCDs govern the majority of skin substitute and grafting claims:
L33831 -- CGS Administrators (Jurisdictions 6 and 15). Specifies covered ICD-10 codes, required documentation of failed conservative therapy, wound measurement requirements, and application frequency limits for chronic non-healing wounds.
L37166 -- Novitas Solutions (Jurisdictions 2, 3, 4, and 12). Defines covered wound etiologies, medical necessity criteria, documentation requirements including wound duration and treatment history, and restrictions on concurrent product use.
L38720 -- Palmetto GBA (Jurisdictions 1 and 11). Includes covered diagnosis lists, conservative treatment requirements, wound bed preparation criteria, and per-visit documentation standards.
Each LCD has a companion Local Coverage Article (LCA) with billing and coding guidance -- covered CPT/HCPCS codes, ICD-10 code lists, and utilization parameters. The Article is as binding as the LCD itself.
What does an LCD specify?
A wound care LCD defines five categories of requirements:
- Covered diagnoses. A finite ICD-10 code list establishing medical necessity. If the wound diagnosis is not on the list, the claim denies regardless of clinical indication.
- Documentation requirements. Elements that must appear in the record -- wound etiology, measurements (length, width, depth), wound bed description, infection status, vascular adequacy, and prior treatment history. A single missing element can trigger denial on audit.
- Conservative treatment criteria. Most LCDs require documentation that conservative therapy was attempted and failed before advanced treatments are covered -- typically 30 days without adequate healing progress.
- Frequency and quantity limits. How often a skin substitute can be applied (commonly weekly), maximum applications per wound episode, and square centimeter limits per application.
- Contraindications and exclusions. Situations where the service is not covered -- active wound site infection, inadequate vascular supply, or wounds not debrided before graft application.
How do I find my MAC's LCD?
The CMS Medicare Coverage Database (medicare.coverage.cms.gov) is the authoritative source. Search by LCD number, CPT/HCPCS code, or keyword. Each entry includes the full policy text, associated Article, effective date, and revision history.
Your MAC is determined by the state where the service is rendered, not where the practice is headquartered. LCDs are revised periodically -- the revision supersedes the prior version on its effective date, and practices that do not track updates risk billing against outdated criteria.
Why does LCD compliance matter?
Non-compliance results in claim denial. MAC claims processing systems apply LCD criteria algorithmically -- a skin substitute claim with a diagnosis code not on the LCD's covered list auto-denies before a human reviewer sees it.
The consequences compound:
- Denied claims require appeals. Appeals consume staff time, delay payment 60-120 days, and have inconsistent overturn rates.
- Pattern denials trigger audits. Repeated LCD denials flag the practice for prepayment review or post-payment audit across the entire review period.
- Post-payment recoupment. If an audit finds services were billed without meeting LCD criteria, the MAC recoups payments already made -- with interest.
LCD compliance is the threshold requirement for getting wound care claims paid. A clinically excellent practice that documents poorly against LCD criteria will collect less than an average practice that documents to LCD requirements consistently.
For a deeper look at operationalizing compliance, see our LCD compliance guide. For how LCDs govern skin substitute billing -- product-specific HCPCS codes and frequency limits -- see our skin substitute billing reference.