Key facts for NCD 130.5
- Benefit category
- Incident to a physician's professional Service
- Effective date
- This is a longstanding national coverage determination. The effective date of this version has not been posted.
- Transmittal
- n/a
- Versions published
- 1
- Manual chapter
- 130
- NCD Manual (Pub. 100-03)
TL;DR
NCD 130.5 sets Medicare's national policy for treatment of alcoholism and drug abuse in a freestanding clinic under the benefit category "Incident to a physician's professional Service", effective This is a longstanding national coverage determination. The effective date of this version has not been posted.. Coverage is available for alcoholism or drug abuse treatment services (such as drug therapy, psychotherapy, and patient education) that are provided incident to a physician's professional service in a freestanding clinic to patients who, for example, have… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Indications and limitations of coverage
Coverage is available for alcoholism or drug abuse treatment services (such as drug therapy, psychotherapy, and patient education) that are provided incident to a physician's professional service in a freestanding clinic to patients who, for example, have been discharged from an inpatient hospital stay for the treatment of alcoholism or drug abuse or to individuals who are not in the acute stages of alcoholism or drug abuse but require treatment. The coverage available for these services is subject to the same rules generally applicable to the coverage of clinic services. Of course, the services also must be reasonable and necessary for the diagnosis or treatment of the individual's alcoholism or drug abuse. The Part B psychiatric limitation would apply to alcoholism or drug abuse treatment services furnished by physicians to individuals who are not hospital inpatients.
Text reproduced from the CMS Medicare Coverage Database record for NCD 130.5 version 1. View the original on cms.gov.
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 130.5
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 130.5
What does NCD 130.5 cover?
Coverage is available for alcoholism or drug abuse treatment services (such as drug therapy, psychotherapy, and patient education) that are provided incident to a physician's professional service in a freestanding clinic to patients who, for example, have been discharged from an inpatient hospital stay for the treatment of alcoholism or drug abuse or to individuals who are not in the acute stages of alcoholism or… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 130.5 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.. This is the only published version.
Does a Local Coverage Determination override NCD 130.5?
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.