National Coverage Determination

You’ve heard of them . . . NCDs or National Coverage Determinations. What are they really? Who do they apply to? And how can I learn more?

National Coverage Determinations are specific to the United States healthcare system, and they fall under the Health and Human Services Department (HHS). They are specific coverage determinations which apply to Medicare for items, technology, and services. Part of the rationale behind NCDs is to ensure that healthcare items and services are truly medically necessary. Although specific to Medicare, other payers often follow these same NCDs.

Although sometimes thought by the layperson out there to cover everything, Medicare healthcare coverage does have limitations for certain items and services that are reasonable and necessary for a particular diagnosis or treatment for an illness or injury. These NCDs are made/developed through a medical evidence-based process in which there are opportunities for public input.

Section 4554(b)(1) of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105– 133) enacted on August 5, 1997, mandated the use of a negotiated rulemaking committee to develop national coverage and administrative policies for clinical diagnostic laboratory services payable under Medicare Part B by January 1, 1999. Section 4554(b)(2) of the BBA required that these national coverage policies be designed to promote program integrity and national uniformity and simplify administrative requirements for clinical diagnostic laboratory services payable under Medicare Part B

Looking back many years to the late 1990’s and early 2001 and 2002, there was a focus on NCDs: Document ( I had the privilege to serve on a national coding committee for Laboratory NCDs (Part B) in 1998 and 1999. This committee made up of physicians, coding professionals and some Medicare regulators reviewed the ICD-9-CM codes (at the time) that would meet medical necessity for around twenty-three (23) different but common laboratory tests for the Medicare population. Since that time the NCDs for laboratory testing has taken hold with coding compliance often oversees editing software to check for NCD acceptance or not. In addition, most laboratory tests that are covered by Medicare has an associated transmittal that describes the lab test and the clinical indicators, includes ICD-10-CM codes that are acceptable. Visit the following to learn more: Lab NCDs – ICD-10 | CMS

Medicare carriers, intermediaries, contractors, quality improvement organizations, health maintenance organizations, competitive health plans, and healthcare prepayment plans are required to follow the NCD.  According to the February 2005 Federal Register, CMS developed an electronic edit table module that is installed in each of the Medicare claims processing contractors’ systems. The edit module ensures that: (1) Each contractor matches diagnosis to procedures in the same manner; (2) competing laboratories in an area will have their claims processed identically regardless of whether they are processed by the carrier or fiscal intermediary; and (3) all local contractors will have implemented the laboratory NCDs at the same time. The edit module is updated quarterly as necessary to accommodate coding changes and NCD modifications.

CMS published a recent MedLearn Network article (August 2021) regarding changes to some specific NCDs regarding the relevant NCD coding changes in CR 12399 include: • NCD 20.4 – Implantable Cardiac Defibrillators (ICDs) • NCD 110.23 – Stem Cell Transplants • NCD 110.24 – Chimeric Antigen Receptor (CAR) T-cell Therapy • NCD 150.13 – Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) • NCD 160.18 – Vagus Nerve Stimulation (VNS) • NCD 210.14 – Low-Dose CT for Lung Cancer Screening.   Use the following link to access the recent CMS MLN Matters Number: MM12399: MM12399 ( To learn more about the Transmittal 10963 regarding: International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)–January 2022; the link for document is at: R10963OTN (

CMS tells us that: Coding (as well as payment) is a separate and distinct area of the Medicare Program from coverage policy/criteria. Revisions to codes within an NCD are carefully and thoroughly reviewed and vetted by the Centers for Medicare & Medicaid Services and are not intended to change the original intent of the NCD. The exception to this is when coding revisions are released as official implementation of new or reconsidered NCD policy following a formal national coverage analysis.

Keep in mind that CMS also states: In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD). Another great NCD resource is the CMS site dedicated to NCDs: Medicare Coverage Determination Process | CMS. In addition, CMS has a Medicare Coverage Database site:

Learn more about NCDs through the links provided above. For HIM Coding professionals, it’s important to remember that a claim for a clinical diagnostic laboratory service must include a valid ICD-10-CM diagnosis code. When a diagnosis has not been established by the physician, codes that describe symptoms and signs, as opposed to diagnoses, should be provided. All digits required by ICD-10-CM coding conventions must be used. A code is invalid if it has not been coded with all digits/characters required for that code.

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