Key facts for NCD 10.1
- Benefit category
- Diagnostic Tests (other), Physicians' Services
- Effective date
- 08/31/1992
- Transmittal
- Transmittal 61
- Versions published
- 1
- Manual chapter
- 10
- NCD Manual (Pub. 100-03)
TL;DR
NCD 10.1 sets Medicare's national policy for use of visual tests prior to and general anesthesia during cataract surgery under the benefit category "Diagnostic Tests (other), Physicians' Services", effective 08/31/1992. Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Indications and limitations of coverage
A. Pre-Surgery Evaluations
Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used. For patients with a dense cataract, an ultrasound B-scan may be used.
Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented.
Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by A/B Medicare Administrative Contractor's medical staff, they are covered.
B. General Anesthesia
The use of general anesthesia in cataract surgery may be considered reasonable and necessary if, for particular medical indications, it is the accepted procedure among ophthalmologists in the local community to use general anesthesia.
Text reproduced from the CMS Medicare Coverage Database record for NCD 10.1 version 1. View the original on cms.gov.
Revision history
08/1992 - Renamed title to indicate more clearly its subject matter. Effective date 08/31/1992. (TN 61)
09/1988 - Provided that Medicare payment not routinely made for pre-cataract surgery exams other than comprehensive eye exam and A-scan or B-scan. Other tests only paid if diagnosis in addition to cataract is present and medical need for other tests fully documented. 09/14/1988. (TN 31)
03/1986 - Eliminated prior references to routine coverage of assistant surgeon's services. All claims for services of surgeons assisting at cataract surgery are subject to carrier medical review. Effective date NA. (TN 5)
How this NCD shows up on remittances
A service denied under a National Coverage Determination returns CARC 50 (not deemed medically necessary) with remark N386 (decision based on an NCD); a denial citing a local policy instead carries N115. Because NCDs bind nationally, the appeal path is documentation that the patient meets the indications above, not a contractor-policy argument.
How QuickIntell applies NCD 10.1
QuickAuth checks the ordered service and diagnosis against NCD and LCD criteria before the encounter, QuickCode validates the diagnosis pairing on the claim, and QuickRCM routes CARC 50 denials with the policy text and the covered-code list attached so the appeal starts with evidence.
Frequently asked questions — NCD 10.1
What does NCD 10.1 cover?
Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 10.1 take effect?
The current version (1) is effective 08/31/1992, published in transmittal 61. This is the only published version.
Does a Local Coverage Determination override NCD 10.1?
No. A National Coverage Determination binds all Medicare Administrative Contractors; an LCD can only address services or circumstances the NCD leaves open. Claims denied under this NCD typically return CARC 50 with remark N386 (NCD) rather than N115 (LCD).
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database NCDs via the CMS Coverage APIVersion API snapshot 2026-09-27 · effective 2026-09-20 · file national-coverage-ncd.jsonSHA-256 a90fadfd264b9ef4…
Disclaimer
This page reproduces the CMS National Coverage Determination text and, for laboratory NCDs, the CMS ICD-10 edit lists, as an operational reference. Coverage decisions depend on the full policy, the claim and the contractor; nothing here is legal, clinical or billing advice. CPT codes are shown as numbers only; CPT descriptors are copyright AMA.