Key facts for NCD 10.4
- Benefit category
- Outpatient Hospital Services Incident to a Physician's Service
- Effective date
- This is a longstanding national coverage determination. The effective date of this version has not been posted.
- Transmittal
- Transmittal 32
- Versions published
- 1
- Manual chapter
- 10
- NCD Manual (Pub. 100-03)
TL;DR
NCD 10.4 sets Medicare's national policy for outpatient hospital pain rehabilitation programs under the benefit category "Outpatient Hospital Services Incident to a Physician's Service", effective This is a longstanding national coverage determination. The effective date of this version has not been posted.. Coverage of services furnished under outpatient hospital pain rehabilitation programs, including services furnished in group settings under individualized plans of treatment, is available if the patient’s pain is attributable to a physical cause, the usual… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Item or service described
Some hospitals also provide pain rehabilitation programs for outpatients. In such programs, services frequently are provided in group settings even though they are being furnished pursuant to each patient's individualized plan of treatment.
Indications and limitations of coverage
Coverage of services furnished under outpatient hospital pain rehabilitation programs, including services furnished in group settings under individualized plans of treatment, is available if the patient’s pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability by the patient to function independently has resulted from the pain. If a patient meets these conditions and the program provides services of the types discussed in §10.3, the services provided under the program may be covered. Non-covered services (e.g., vocational counseling, meals for outpatients, or acupuncture) continue to be excluded from coverage, and A/B Medicare Administrative Contractors would not be precluded from finding, in the case of particular patients, that the pain rehabilitation program is not reasonable and necessary under §1862(a)(1) of the Social Security Act for the treatment of their conditions.
Text reproduced from the CMS Medicare Coverage Database record for NCD 10.4 version 1. View the original on cms.gov.
Revision history
09/1988 - Clarified that services furnished under outpatient hospital pain rehabilitation programs are covered if patient's pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability by patient to function independently has resulted from the pain. Effective date NA. (TN 32)
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 10.4
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 10.4
What does NCD 10.4 cover?
Coverage of services furnished under outpatient hospital pain rehabilitation programs, including services furnished in group settings under individualized plans of treatment, is available if the patient’s pain is attributable to a physical cause, the usual methods of treatment have not been successful in alleviating it, and a significant loss of ability by the patient to function independently has resulted from the… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 10.4 take effect?
The current version (1) is effective This is a longstanding national coverage determination. The effective date of this version has not been posted., published in transmittal 32. This is the only published version.
Does a Local Coverage Determination override NCD 10.4?
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.