Glossary / NCD
NCD National Coverage DeterminationNCD (National Coverage Determination)
A CMS coverage decision that applies nationwide and binds every MAC; where no NCD exists, the MACs may set coverage through LCDs.
A National Coverage Determination (NCD) is a decision by CMS itself about whether Medicare covers an item or service, issued under Section 1862(l) of the Social Security Act. It applies uniformly across the country and every Medicare Administrative Contractor must follow it. When an NCD exists, a MAC cannot write a local policy that contradicts it.
Where there is no NCD, or the NCD leaves room, MACs may develop Local Coverage Determinations or decide claims case by case. For most DME categories the detailed criteria you document against are in the DME MACs' joint LCDs and their policy articles, with any applicable NCD sitting above them.
Both NCDs and LCDs are published in the Medicare Coverage Database, which is the authoritative place to check which policies govern a HCPCS code and whether they have changed.
Common questions
Does an NCD override an LCD?
Yes. An NCD is national policy; an LCD can only fill in where the NCD is silent.
Which policy do I document against for CPAP or oxygen?
Search the Medicare Coverage Database by HCPCS code; it returns any NCD plus the DME MAC LCD and policy article for the item. The documentation criteria for PAP and oxygen are spelled out in L33718 and L33797.
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Sources: CMS: Medicare Coverage Determination Process · CMS Medicare Coverage Database . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Prior authorization
- Affirmation and non-affirmation
- UTN — Unique Tracking Number
- SWO — Standard Written Order
- Face-to-face encounter
- DME MAC — Durable Medical Equipment Medicare Administrative Contractor
- Jurisdiction
- PTAN — Provider Transaction Access Number
- NPI — National Provider Identifier
- MBI — Medicare Beneficiary Identifier
- LCD — Local Coverage Determination
- Policy article
- HCPCS — Healthcare Common Procedure Coding System
- Length of need
- Prior authorization exemption
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- TPE — Targeted Probe and Educate
- Prepayment review