NCDs and LCDs: How to Check Medicare Coverage

For many tests and procedures, Medicare has already decided which conditions make them necessary. Those decisions are published as coverage determinations, and they are free to search.

Part 1 of 4

Three kinds of coverage documents

Document	Written by	Applies to	What it contains
NCD (National Coverage Determination)	CMS	All of Medicare, in every state	When a service is covered nationally, not covered, or covered with conditions
LCD (Local Coverage Determination)	A Medicare Administrative Contractor (MAC)	That MAC's region (jurisdiction) only	When a service is "reasonable and necessary" in that region
Billing and coding article	The MAC (linked to an LCD or NCD)	Same as its LCD	The CPT/HCPCS codes, covered ICD-10-CM codes, modifiers and billing rules

An LCD may only set "reasonable and necessary" rules. The coding details, including the diagnosis list, sit in the article that goes with it. When the LCD and an NCD cover the same service, the NCD wins.

Key point

The LCD tells you when a service is necessary. Its article tells you which codes prove it.

Done: Coverage documents

Part 2 of 4

How to look up a service

Go to the Medicare Coverage Database (MCD) at cms.gov/medicare-coverage-database.
Search by the CPT/HCPCS code or a keyword (for example "vitamin D" or 82306).
Pick the state where the service was given, so you see the right MAC's LCDs.
Open the NCD or LCD and read the coverage indications: who qualifies, what must be documented, how often.
Open the linked billing and coding article and find the section titled "ICD-10-CM codes that support medical necessity." Check the service's diagnosis against that list.
Look for frequency limits, required modifiers, and any rule that needs two diagnoses together (some articles list codes that must be paired).

Read the notes under the code list

Many articles say a code is covered only with another code, only for certain ages, or only a set number of times a year. The list alone does not tell the whole story.

Done: Looking up a service

Part 3 of 4

National lab NCDs

Medicare has a set of national lab NCDs (the "190" series in the NCD Manual) for common tests such as lipid panels, HbA1c, thyroid tests, PSA, blood counts and urine cultures. CMS publishes a list of covered and non-covered ICD-10-CM codes for each one, updated every quarter.

Example

Lipid panel (NCD 190.23)

Diagnostic lipid panel (80061). NCD 190.23 covers lipid testing to evaluate and follow patients with signs, symptoms or conditions that affect lipids, such as known heart disease, diabetes or high cholesterol. For patients on long-term lipid-lowering diet or drug therapy, or with borderline high total or LDL cholesterol, testing about once a year is usually considered reasonable.

Screening. Medicare covers cardiovascular screening blood tests (80061, 82465, 83718, 84478) for patients with no signs or symptoms of heart disease once every 5 years, reported with Z13.6 (encounter for screening for cardiovascular disorders). Routine screening under the diagnostic NCD is not covered.

So the same lipid panel is:

Covered for a patient on a statin, with the hyperlipidemia code (for example E78.5) and long-term drug therapy code (Z79.899).
Covered once every 5 years as screening with Z13.6.
Likely denied if a healthy patient had screening 2 years ago and has no documented reason now.

Frequency limits

Many services are necessary only so often. Common examples:

Screening tests (lipids every 5 years, screening colonoscopy at set intervals).
Repeat lab tests (a test repeated within days without a change in the patient's condition).
Therapy visits and injections with a set number per period.

When a service exceeds its limit, the record must show why this patient needed it again: a new symptom, a changed drug, an abnormal earlier result. Without that, it is denied for frequency (often CARC 151 or 119).

Done: Lab NCDs and frequency

Part 4 of 4

Medicare Advantage and commercial payers

Medicare Advantage plans must follow Medicare's NCDs and LCDs and general coverage rules. They can add their own criteria only where Medicare's rules are not fully set, and they often require prior authorization.
Commercial payers publish their own medical (clinical) policies. Search the payer's provider site for the service. The structure is similar: covered indications, covered codes, limits.

Note

Coverage rules change every quarter. Check the version date of the LCD, article or payer policy against the date of service, not today's date.

Check yourself

Where do you find the list of ICD-10-CM codes that support medical necessity for a service under an LCD?

The LCD itselfThe billing and coding articleThe CPT bookThe NCCI edits

An NCD and an LCD both address the same service. Which one controls?

The NCDThe LCDWhichever is newer

A patient with no heart symptoms had a screening lipid panel 3 years ago. A new screening panel is ordered with Z13.6. What happens under Medicare?

Paid: screening is always coveredLikely denied: the limit is once every 5 yearsPaid with modifier 33

Done: Other payers and check