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National Coverage Determination (NCD)

Treatment of Kidney Stones

230.1

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Tracking Information

Publication Number
100-3
Manual Section Number
230.1
Manual Section Title
Treatment of Kidney Stones
Version Number
1
Effective Date of this Version
01/16/1988
Ending Effective Date of this Version
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Traditional approaches for the treatment of kidney stones are the surgical technique nephrectomy (or nephrotomy) and endoscopic treatments via the urethra. In the last few years, several new approaches in the surgical management of upper urinary tract kidney stones have been developed, among them invasive and non-invasive lithotripsy techniques.
Indications and Limitations of Coverage

In addition to the traditional surgical/endoscopic techniques for the treatment of kidney stones, the following lithotripsy techniques are also covered for services rendered on or after March l5, l985.

A. Extracorporeal Shock Wave Lithotripsy

Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive method of treating kidney stones using a device called a lithotriptor. The lithotriptor uses shock waves generated outside of the body to break up upper urinary tract stones. It focuses the shock waves specifically on stones under X-ray visualization, pulverizing them by repeated shocks. ESWL is covered under Medicare for use in the treatment of upper urinary tract kidney stones.

B. Percutaneous Lithotripsy

Percutaneous lithotripsy (or nephrolithotomy) is an invasive method of treating kidney stones by using ultrasound, electrohydraulic or mechanical lithotripsy. A probe is inserted through an incision in the skin directly over the kidney and applied to the stone. A form of lithotripsy is then used to fragment the stone. Mechanical or electrohydraulic lithotripsy may be used as an alternative or adjunct to ultrasonic lithotripsy. Percutaneous lithotripsy of kidney stones by ultrasound or by the related techniques of electrohydraulic or mechanical lithotripsy is covered under Medicare.

The following is covered for services rendered on or after January 16, 1988.

C. Transurethral Ureteroscopic Lithotripsy

Transurethral ureteroscopic lithotripsy is a method of fragmenting and removing ureteral and renal stones through a cystoscope. The cystoscope is inserted through the urethra into the bladder. Catheters are passed through the scope into the opening where the ureters enter the bladder. Instruments passed through this opening into the ureters are used to manipulate and ultimately disintegrate stones, using either mechanical crushing, transcystoscopic electrohydraulic shock waves, ultrasound or laser. Transurethral ureteroscopic lithotripsy for the treatment of urinary tract stones of the kidney or ureter is covered under Medicare.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
21
Revision History

01/1988 - Covered transurethral ureteroscopic lithotripsy for the treatment of urinary tract stones of kidney or ureter. Effective date 01/16/1988. (TN 21)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Treatment of Kidney Stones 1 01/16/1988 - N/A You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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