Medicare Coverage for Common Endocrine Services

National and Local Medicare Coverage Determinations

What are NCDs and LCDs?   

NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary on certain services offered by participating providers. 

What is the difference between a NCD and an LCD? 

An NCD is mandated at the national level and all FIs, Carriers, and Medicare Administrative Contractors (MACs) follow those guidelines.  An LCD is mandated at the MAC level and those guidelines are only applicable to that MAC’s jurisdiction. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual

What is part of an NCD/LCD? 

Codes describing what is covered and what is not covered can be part of the NCD/LCD. This includes, for example, lists of HCPCs codes that spell out which services the NCD/LCD applies to, lists of ICD-10-CM codes for which the service is covered, lists of ICD-10 codes for which the service is not considered reasonable and necessary, etc.  

What do NCD/LCDs specify? 

The NCD/LCDs specify under what clinical circumstances a service is considered reasonable and necessary.  

What are NCD/LCDs used for? 

They are administrative and educational tools to assist providers in submitting correct claims for reimbursement.  

Who publishes and develops NCD/LCDs? 

Medicare Administrative Contractors (MACs) publish LCDs to provide guidance to the public and medical community within their jurisdictions.  MACs develop LCDs by considering medical literature, the advice of local medical societies and medical consultants, public comments, and comments from the provider community. Significant changes to the LCD process begin January 2020.  The Medicare Coverage Determination process for National Coverage Determinations (NCDs) are made through an evidence-based process, with opportunities for public participation.   

Can an NCD/LCD be reconsidered? 

NCD/LCDs can be reconsidered.  The NCD reconsideration process can be found here and each Medicare administrative contractor will have the reconsideration process on their website.  A list of all MAC websites can be found here

Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report as of July 2019.   

Common endocrine NCDs with their associated national coverage policy numbers. 

  • Blood Glucose Testing 190.20  

  • Glycated Hemoglobin/Glycated Protein 190.21   

  • Thyroid Testing 190.22  

  • Lipids Testing 190.23  

  • Prostate Specific Antigen 190.31  

  • Bone Density 150.3  

  • Diabetes Outpatient Self-Management Training 40.1 

  • Intensive Behavioral Therapy for Obesity 210.12  

 

You must know your local Medicare Administrative contractor (MAC) before searching for common endocrine LCDs.  Here is a list of all MACs.  This is not all-inclusive list. 

  • Assays for vitamins and metabolic functions 

  • HGBA1C 

  • DXA 

  • Diagnostic Ultrasounds 

  • DSMT 

  • MNT 

  • Vitamin B12  

  • Vitamin D 

  • CGM 

  • Noninvasive physiological physiological studies (93922-92931) 

  • Autonomic Function 

  • Routine Foot Care 

  • Lipid 

  • Glucose 

  • Thyroid 

  • Hydration therapy 

  • GlycoMark Testing for Glycemic Control 

  • Treatment of Males with Low Testosterone 

All LCDs please note you must know who your Local Medicare Administrative contractor is

Durable Medical Equipment (DME) LCDs for: 

  • Glucose Monitors 

  • Therapeutic Shoes for Diabetics 

All DME NCDs please note you must know who your Local Medicare Administrative contractor is