Treatment of Kidney Stones — NCD 106 | CMS Coverage Update

CMS modified NCD 106 governing kidney stone treatment coverage, effective March 7, 2026. Here's what billing teams need to know.

The Centers for Medicare & Medicaid Services updated NCD 106 in the Medicare system, covering three distinct lithotripsy techniques for upper urinary tract kidney stones. This coverage policy encompasses extracorporeal shock wave lithotripsy (ESWL), percutaneous lithotripsy, and transurethral ureteroscopic lithotripsy. The policy does not list specific CPT or HCPCS codes in the current document — a gap your billing team needs to address directly.

Quick-Reference Table

CMS Kidney Stone Lithotripsy Coverage Criteria and Medical Necessity Requirements 2026

NCD 106 in the Medicare system covers kidney stone treatment across three surgical approaches. The coverage policy draws a clear line between traditional techniques and newer lithotripsy methods — and Medicare covers all of them.

The traditional approaches — nephrectomy, nephrotomy, and endoscopic treatments via the urethra — remain covered. But the more significant billing question for most urology and nephrology practices involves the three lithotripsy techniques. CMS has covered these since the mid-1980s, and this modification reaffirms that coverage framework.

Extracorporeal Shock Wave Lithotripsy (ESWL) is the non-invasive option. The lithotriptor generates shock waves outside the body and focuses them on upper urinary tract stones under X-ray visualization. Medicare covers ESWL for upper urinary tract kidney stones. Coverage began March 15, 1985.

Percutaneous lithotripsy — also called nephrolithotomy — is the invasive alternative. A probe goes through a skin incision directly over the kidney. The policy covers ultrasonic lithotripsy as the primary technique, with electrohydraulic and mechanical lithotripsy covered as alternatives or adjuncts. Medical necessity for this approach is established by the stone's location and the clinical judgment that percutaneous access is appropriate.

Transurethral ureteroscopic lithotripsy covers a wider anatomical range — both ureteral and renal stones. The cystoscope enters through the urethra into the bladder, with instruments passed into the ureters to fragment stones. Medicare covers mechanical crushing, electrohydraulic shock waves, ultrasound, and laser fragmentation under this technique. Coverage began January 16, 1988.

The real issue for your billing team: each of these techniques has its own clinical pathway, its own documentation requirements, and its own coding footprint. A claim denial is most likely when the operative note doesn't clearly establish which technique was used — or when a combination approach isn't documented as an alternative or adjunct.

The policy does not specify prior authorization requirements at the NCD level. That said, your Medicare Administrative Contractor may have a local coverage determination that adds prior auth requirements or additional documentation standards on top of this NCD. Check with your MAC before assuming this is a clean-bill situation.

For reimbursement, rates depend on the specific CPT codes your team bills — and NCD 106 does not list those codes. More on that below.

Coverage Indications at a Glance

CMS Kidney Stone Lithotripsy Billing Guidelines and Action Items 2026

The effective date of March 7, 2026 means this modification is live. Don't wait to audit your workflows.

If you're uncertain how this policy update intersects with your payer mix or case volume, talk to your billing consultant before the next quarterly audit cycle. The stakes are medium-level, but a pattern of miscoded lithotripsy claims can trigger a focused review.

CPT, HCPCS, and ICD-10 Codes for Kidney Stone Treatment Under NCD 106

Important: NCD 106 does not list specific CPT, HCPCS, or ICD-10 codes in the current policy document. This is a meaningful gap for kidney stone lithotripsy billing. The codes below are commonly associated with these procedures in clinical practice, but your team must verify applicable codes against CMS claims processing instructions and your MAC's LCD before billing.

Covered Techniques (Per NCD 106 — Codes Not Specified in Policy)

The CMS claims processing instructions cross-referenced in NCD 106 are the authoritative source for the specific CPT codes that map to each covered technique. Pull those instructions and align your charge master accordingly.

Where This Policy Leaves Billing Teams — and What to Watch

The absence of explicit CPT codes in NCD 106 is the biggest practical frustration here. A national coverage determination that confirms coverage for three distinct lithotripsy techniques but doesn't specify the codes that trigger that coverage puts the burden squarely on your billing team to make the connection.

This isn't unusual for older NCDs — NCD 106 has roots going back to 1985 — but it means your MAC's local coverage determination and CMS's claims processing instructions are doing more work than the NCD itself. Don't treat the NCD as a standalone billing guide. It isn't one.

The medical necessity documentation burden is real for all three techniques, but percutaneous lithotripsy cases carry the highest risk. The policy's language around electrohydraulic and mechanical lithotripsy as "alternatives or adjuncts" to ultrasonic means you need clear documentation of why the adjunct was used. "Used laser because physician preference" won't hold up to a medical necessity review. The operative note needs clinical rationale.

For practices billing transurethral ureteroscopic lithotripsy, the expanded anatomical scope — both ureteral and renal stones — is worth flagging for your coding team. Make sure your ICD-10 diagnosis codes match the stone location documented in the procedure note. A renal stone diagnosis paired with a ureteroscopic code needs the operative note to confirm the scope reached the renal pelvis.