Knowledge Base Article

Q:

Our hospital sometimes receives automated medical necessity denials related to a National Coverage Determination (NCD). Where can I find a listing of the acceptable ICD-10 diagnosis codes that support medical necessity for services with an NCD?

A:

Although a listing of the covered diagnoses is not available for all NCDs, you can find many of them on CMS’s Medicare Coverage General Information ICD-10.  At the bottom of the page, there is a table, “Links related to ICD-10 NCDs (as of 05/13/2019).” This table contains links to all the transmittals concerning code changes for NCDs “related to ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.”

The easiest way to find code edits for a particular NCD is to do a search for the NCD number on this webpage. Select “Find” from the Menu option or “Control+F,” and enter the NCD number in the search box. If you need to find the current ICD-10 requirements for a service, choose the latest transmittal by date that contains the NCD number you are looking for. If you are looking for the requirements for a certain point in time, select the transmittal that addresses the relevant NCD and is from the last transmittal date prior to the date you are interested in.

Once you select the correct transmittal, find the link in the transmittal to the NCD spreadsheets included with the related Change Request Transmittal (CR). This will open a file with spreadsheets for all the NCDs with revisions at the time of the date of the transmittal. Select the NCD/service you are researching and open the spreadsheet. The spreadsheets have tabs for “ICD Diagnosis,” “ICD Procedures,” and “Rule Description” which contain the expected information. Medicare contractors use these edit tables to control Medicare coverage with automated denials if a required diagnosis is not present on the claim. Being aware of the specific codes required can assist hospitals in being proactive about Medicare coverage with education and the use of Advance Beneficiary Notices (ABNs).

Notice in the title of the table referenced above, that the title includes an “as of” date. For dates after the as of date, I recommend searching the current transmittal listing for the term “NCD” or “ICD-10.” Also sign up for Medicare transmittal updates through Medicare’s Listserv Signup so that you will aware for any changes in these edits and other Medicare information. At the link above, scroll to the bottom right of the page to find a “Receive Email Updates” box where you can enter your email address to receive updates.