Medicare Lab NCDs and LCDs: How Lab Test Coverage Works

The coverage baseline

Medicare Benefit Policy Manual Ch. 15 § 80.1 lays out the base rules:

• Lab services must meet CLIA (42 CFR 493).

• Lab services must be reasonable and necessary under SSA § 1862(a)(1)(A).

• Lab services must be ordered, and the results used promptly, by the physician treating the beneficiary or a qualified nonphysician practitioner, under 42 CFR 410.32(a).

NCDs: national rules

The CMS coverage basics page explains that most Medicare coverage decisions are made locally by contractors. NCDs are the exception: CMS issues them, and they apply nationally. NCDs are published in the Medicare National Coverage Determinations Manual (Pub. 100-03).

Lab NCDs: Chapter 1, Part 3 of the NCD Manual has 23 negotiated lab NCDs, numbered 190.12 through 190.34. They cover tests such as urine culture, HIV testing, blood counts, PT/PTT, serum iron, blood glucose, glycated hemoglobin, thyroid, lipids, digoxin, tumor markers (AFP, CEA, hCG, CA 125, CA 15-3/27.29, CA 19-9, PSA), GGT, the hepatitis panel, and fecal occult blood. Each NCD lists the covered indications and the ICD-10-CM codes. CMS updates those code lists through change requests. These NCDs came from the negotiated rulemaking final rule (66 FR 58788, Nov. 23, 2001).

LCDs: local rules

The CMS Local Coverage Determinations page explains that MACs develop LCDs when no NCD applies, or to clarify one. An LCD decides only whether a service is reasonable and necessary. LCDs come from SSA § 1869(f)(2)(B), and the process is in Program Integrity Manual Ch. 13. LCDs often come with billing and coding articles that list codes and documentation expectations. Coverage for the same test can vary by MAC jurisdiction. Find your MAC.

How to look up coverage

1. Open the Medicare Coverage Database (MCD).

2. Search by CPT/HCPCS code or test name, then filter by your state or MAC.

3. Read any NCD, LCD, and billing and coding article that applies, plus its ICD-10 code lists.

4. Confirm that the documentation from the ordering practitioner supports medical necessity.

When coverage is uncertain: the ABN

If you expect Medicare to deny a test as not reasonable and necessary (for example, the diagnosis isn't on an NCD or LCD list), give the patient an Advance Beneficiary Notice of Noncoverage (ABN) before the test is done. If you don't, the lab may not be able to bill the patient. See Claims Processing Manual Ch. 30 and the ABN modifiers it describes.

Coverage checklist

1. ☐ Map each test on your menu to any NCD (190.12–190.34) or LCD that applies.

2. ☐ Save the MCD links for your MAC's LCDs and billing and coding articles.

3. ☐ Build diagnosis-code checks into order entry.

4. ☐ Confirm a treating physician or NPP ordered the test, with supporting documentation.

5. ☐ Issue ABNs before testing when you expect a denial.

6. ☐ Review NCD code-list change requests each quarter.

7. ☐ Track LCD proposals and comment periods.

FAQs

What is the difference between an NCD and an LCD?

CMS issues an NCD, and it applies nationwide. A MAC issues an LCD, and it applies only in that MAC's jurisdiction.

How many lab NCDs are there?

Chapter 1, Part 3 of the NCD Manual has 23 lab NCDs, numbered 190.12 through 190.34.

Where do I look up an LCD?

In the CMS Medicare Coverage Database. Filter by your MAC or state.

Does an NCD override an LCD?

An LCD can't conflict with an NCD. MACs write LCDs when no NCD applies, or to add detail.

What if a diagnosis isn't on the covered list?

Medicare may deny the claim. If you expect a denial, issue an ABN before the test is done.

Who can order Medicare lab tests?

The treating physician or a qualified nonphysician practitioner, under 42 CFR 410.32(a).

Related pages

Medicare lab billing basics, Medicare CLFS, clinical lab billing, and what is CLIA.

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