Key facts for NCD 220.13
- Benefit category
- Ambulatory Surgical Center Facility Services, Inpatient Hospital Services, Outpatient Hospital Services Incident to a Physician's Service, Physicians' Services
- Effective date
- 01/01/2003
- Implemented 01/01/2003
- Transmittal
- Transmittal 159
- Versions published
- 1
- Manual chapter
- 220
- NCD Manual (Pub. 100-03)
TL;DR
NCD 220.13 sets Medicare's national policy for percutaneous image-guided breast biopsy under the benefit category "Ambulatory Surgical Center Facility Services, Inpatient Hospital Services, Outpatient Hospital Services Incident to a Physician's Service, Physicians' Services", effective 01/01/2003 and implemented 01/01/2003. Effective January 1, 2003, Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is non-palpable and is graded as a BIRADS III, IV, or V. It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Item or service described
Percutaneous image-guided breast biopsy is a method of obtaining a breast biopsy through a percutaneous incision by employing image guidance systems. Image guidance systems may be either ultrasound or stereotactic.
The Breast Imaging Reporting and Data System (or BIRADS system) employed by the American College of Radiology provides a standardized lexicon with which radiologists may report their interpretation of a mammogram. The BIRADS grading of mammograms is as follows: Grade I-Negative, Grade II-Benign finding, Grade III-Probably benign, Grade IV-Suspicious abnormality, and Grade V-Highly suggestive of malignant neoplasm.
Indications and limitations of coverage
A. Non-Palpable Breast Lesions
Effective January 1, 2003, Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is non-palpable and is graded as a BIRADS III, IV, or V.
B. Palpable Breast Lesions
Effective January 1, 2003, Medicare covers percutaneous image guided breast biopsy using stereotactic or ultrasound imaging for palpable lesions that are difficult to biopsy using palpation alone. Medicare Administrative Contractors have the discretion to decide what types of palpable lesions are difficult to biopsy using palpation.
Text reproduced from the CMS Medicare Coverage Database record for NCD 220.13 version 1. View the original on cms.gov.
Revision history
09/2025 - Transmittal 13383 issued August 26, 2025, is being rescinded and replaced by Transmittal 13401, dated September 9, 2025, to add a new attachment to ensure the functionality of the NCD zip URL is working properly and to update the Policy section. All other information remains the same.
The purpose of this Change Request (CR) is to provide a quarterly maintenance update of ICD-10 coding conversions and other coding updates specific to National Coverage Determinations (NCDs). ( TN 13401 ) (CR14194)
04/2023 - Transmittal 11884 issued March 01, 2023, is being rescinded and replaced by Transmittal 11952, dated, April 12, 2023, to remove the A/B MACs (Part A) and FISS from BR 13070.1 and to revise the NCD 20.4 Implantable Automatic Defibrillators (ICDs) spreadsheet. All other information remains the same. ( TN 11952 ) (CR13070)
03/2023 - Transmittal 11832 issued February 02, 2023, is being rescinded and replaced by Transmittal 11884, dated, March 1, 2023 to (1) Business Requirement (BR) 13070.4, NCD 150.3 - delete three non-covered CPT codes added in error and remove reference to ALERT M38; (2) BR 13070.1, NCD 20.4 - clarify that C codes are only payable in the ASC setting; and (3) NCD 220.13 spreadsheet - correct effective date of MSN 21.11 to December 31, 2022 to align with BR 13070.7. All other information remains the same. ( TN 11884 ) (CR13070)
02/2023 - The purpose of the Change Request (CR) is to provide a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. ( TN 11832 ) (CR13070)
10/2021 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. ( TN 11083 ) (CR12482)
01/2021 - Transmittal 10515, dated December 10, 2020, is being rescinded and replaced by Transmittal 10566, dated, January 14, 2021 to remove FISS Reason Codes (RCs) 59041, 59042, 59209, and 59210 from the spreadsheet for NCD 160.18. All other information remains the same. ( TN 10566 ) (CR12027)
12/2020 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, longstanding NCD process. ( TN 10515 ) (CR12027)
10/2020 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, longstanding NCD process. ( TN 10432 ) (CR12027)
09/2019 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received. ( TN 2362 ) (CR11392)
05/2019 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process.( TN 2298 ) (CR11229)
05/2018 - This Change Request (CR) constitutes a maintenance update of ICD-10 conversions and other coding updates specific to NCDs. These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. ( TN 2076 ) (CR10622)
01/2018 - This Change Request (CR) constitutes a maintenance update of International Code of Diseases, Tenth Revision (ICD-10)
conversions and other coding updates specific to National Coverage Determinations (NCDs). These NCD coding changes are the result
of newly available codes, coding revisions to NCDs released separately, or coding feedback received.
Previous NCD coding changes appear in ICD-10 quarterly updates that can be found at: https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html , along with other CRs implementing new policy NCDs. Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent quarterly releases and individual CRs as appropriate. No policy-related changes are included with the ICD-10 quarterly updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. ( TN 2005 ) (CR10318)
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 220.13
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 220.13
What does NCD 220.13 cover?
Effective January 1, 2003, Medicare covers percutaneous image-guided breast biopsy using stereotactic or ultrasound imaging for a radiographic abnormality that is non-palpable and is graded as a BIRADS III, IV, or V. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 220.13 take effect?
The current version (1) is effective 01/01/2003, implemented 01/01/2003, published in transmittal 159. This is the only published version.
Does a Local Coverage Determination override NCD 220.13?
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.