TL;DR: The Centers for Medicare & Medicaid Services modified NCD 106 governing kidney stone treatment coverage, with an effective date of March 7, 2026. Here's what billing teams need to know.
CMS kidney stone coverage policy under NCD 106 in the Medicare system covers three distinct lithotripsy techniques alongside traditional surgical approaches. This update consolidates coverage for extracorporeal shock wave lithotripsy (ESWL), percutaneous lithotripsy, and transurethral ureteroscopic lithotripsy under a single modified policy. The policy does not list specific CPT or HCPCS codes — which creates real billing documentation work for your team.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Medicare) |
| Policy | Treatment of Kidney Stones |
| Policy Code | NCD 106 |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | Medium |
| Specialties Affected | Urology, Interventional Radiology, General Surgery, Nephrology |
| Key Action | Verify your kidney stone treatment claims align with all three covered lithotripsy categories before billing Medicare after March 7, 2026 |
CMS Kidney Stone Treatment Coverage Criteria and Medical Necessity Requirements 2026
The Centers for Medicare & Medicaid Services covers kidney stone treatment under NCD 106 across both traditional surgical methods and three lithotripsy techniques. The coverage policy applies to upper urinary tract stones as well as ureteral and renal stones, depending on the technique used. Medical necessity is the threshold for every claim — and this policy defines that threshold differently for each approach.
ESWL has the broadest coverage language. CMS covers extracorporeal shock wave lithotripsy for upper urinary tract kidney stones, with no additional restriction on stone size, location within the upper tract, or prior treatment failure. The technique uses a lithotriptor to generate shock waves outside the body and focus them on stones under X-ray visualization. If your team bills for ESWL, the medical necessity argument is straightforward: the patient has an upper urinary tract stone.
Percutaneous lithotripsy — also called nephrolithotomy — has equally clean coverage language. CMS covers percutaneous lithotripsy using ultrasound, electrohydraulic, or mechanical lithotripsy techniques. The coverage extends to using mechanical or electrohydraulic lithotripsy as an alternative or adjunct to ultrasonic lithotripsy. That adjunct language matters. It means you can support a claim that combines methods in a single session, provided your documentation shows which technique was primary and which was supplemental.
Transurethral ureteroscopic lithotripsy carries the most detailed procedure description in the policy. Coverage extends to fragmentation and removal of both ureteral and renal stones through a cystoscope inserted via the urethra. The policy explicitly lists mechanical crushing, electrohydraulic shock waves, ultrasound, and laser as covered fragmentation methods. Whether you're billing for laser lithotripsy or ultrasonic ureteroscopic fragmentation, this coverage policy supports the claim — as long as documentation ties the procedure to a kidney or ureteral stone diagnosis.
The policy does not mention prior authorization requirements. That said, CMS coverage policies set the floor, not the ceiling. Your Medicare Administrative Contractor may impose additional prior authorization rules or documentation requirements at the local level. Check with your MAC before assuming the national policy is the whole picture.
Reimbursement rates are not addressed within NCD 106 itself. Those are set through the Medicare Physician Fee Schedule and facility payment schedules separately.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Upper urinary tract kidney stones — ESWL | Covered | Policy does not list specific codes | Covered for services on or after March 15, 1985 |
| Upper urinary tract kidney stones — percutaneous lithotripsy (ultrasound, electrohydraulic, or mechanical) | Covered | Policy does not list specific codes | Mechanical/electrohydraulic may be used as alternative or adjunct to ultrasound |
| Ureteral and renal stones — transurethral ureteroscopic lithotripsy (mechanical, electrohydraulic, ultrasound, or laser) | Covered | Policy does not list specific codes | Covered for services on or after January 16, 1988 |
| Traditional nephrectomy / nephrotomy | Covered | Policy does not list specific codes | Long-standing surgical coverage; not the focus of this NCD update |
| Endoscopic treatments via the urethra (traditional) | Covered | Policy does not list specific codes | Covered alongside lithotripsy techniques |
CMS Kidney Stone Treatment Billing Guidelines and Action Items 2026
The modified policy takes effect March 7, 2026. Here's what your billing team should do before and after that date.
| # | Action Item |
|---|---|
| 1 | Identify every kidney stone claim in your charge capture workflow. This policy covers three distinct lithotripsy techniques under separate coverage criteria. Each technique has its own clinical description and, in some cases, a different coverage start date. Make sure your documentation matches the technique actually performed — ESWL, percutaneous lithotripsy, or transurethral ureteroscopic lithotripsy. |
| 2 | Check with your MAC for local coverage determinations. NCD 106 is a national policy, but Medicare Administrative Contractors issue LCDs that can add documentation requirements, prior authorization rules, or coverage restrictions on top of the NCD. Contact your MAC before March 7, 2026 to confirm whether a relevant LCD exists in your jurisdiction. |
| 3 | Document the specific lithotripsy method in every operative note. This policy differentiates between ultrasound, electrohydraulic, mechanical, and laser techniques. Vague documentation — "lithotripsy performed" — creates medical necessity disputes and increases claim denial risk. Operative notes should name the exact method and, for percutaneous procedures, confirm whether a secondary method was used as an adjunct. |
| 4 | Confirm stone location in your diagnosis documentation. ESWL coverage applies to upper urinary tract stones. Transurethral ureteroscopic lithotripsy coverage extends to both ureteral and renal stones. Your ICD-10-CM diagnosis code must reflect the actual stone location, and your clinical documentation must support it. A mismatch between the procedure code and the documented stone location is a fast path to denial. |
| 5 | Flag the absence of specific CPT and HCPCS codes in this policy. NCD 106 does not list procedure codes. That means your billing team needs to map the covered services to the correct CPT codes independently — using the AMA CPT manual, your MAC's guidance, or your coding software. This is a real gap. If you're not certain which CPT codes align to each lithotripsy technique in your payer mix, consult your billing consultant or coding specialist before the effective date. |
| 6 | Review claims from the past 12 months. If you've had kidney stone lithotripsy claims denied, this policy update is worth reviewing against those denial reasons. Denials tied to medical necessity or incorrect coding may warrant reopening under the modified policy. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Kidney Stone Treatment Under NCD 106
This policy does not list specific CPT, HCPCS, or ICD-10 codes. That's not unusual for an NCD of this age — many foundational coverage determinations were written before code-level specificity became standard in CMS policy documents.
The absence of codes in NCD 106 creates a real billing gap. Your team needs to identify the correct codes independently.
What to Do When an NCD Doesn't List Codes
Contact your Medicare Administrative Contractor directly. MACs often publish companion billing articles alongside NCDs that map the covered services to specific CPT codes. These billing articles carry the same operational weight as the NCD itself for claims processing purposes.
Check the CMS Claims Processing Instructions cross-reference listed in the policy. That reference may point to coding guidance that NCD 106 doesn't contain on its own.
For reference, kidney stone lithotripsy procedures generally fall within the CPT code ranges for urology and the urinary system. Your coding specialist should verify the exact codes for your procedure types. Common procedure categories to review with your coder include ESWL, percutaneous nephrostolithotomy or nephrolithotomy, and ureteroscopy with lithotripsy — but do not bill specific codes based on this blog post alone. Verify through the AMA CPT manual and your MAC's billing guidance.
If your compliance officer isn't already looped in on this, now is the time. The combination of a policy modification, no listed codes, and MAC-level variability is exactly the scenario that creates audit exposure.
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