TL;DR: The Centers for Medicare & Medicaid Services modified NCD 171, the CMS diabetic peripheral neuropathy coverage policy, effective March 7, 2026. Here's what billing teams need to know.
This update to NCD 171 Medicare coverage governs foot exams and treatment for beneficiaries with documented diabetic sensory neuropathy with loss of protective sensation (LOPS). The policy does not list specific CPT or HCPCS codes in the current data, but the clinical and documentation requirements directly affect how you bill evaluation and treatment services for this condition. If your practice sees Medicare patients with diabetes, this policy applies to you.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Services for Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation |
| Policy Code | NCD 171 |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | High |
| Specialties Affected | Podiatry, Primary Care, Endocrinology, Wound Care |
| Key Action | Audit documentation for LOPS diagnosis via 5.07 monofilament testing and confirm the six-month exam interval is tracked per beneficiary |
CMS Diabetic Peripheral Neuropathy Coverage Criteria and Medical Necessity Requirements 2026
The CMS diabetic peripheral neuropathy coverage policy under NCD 171 covers foot exams as a physician service. Coverage applies no more than once every six months. For medical necessity to be established, the beneficiary must have a documented diagnosis of both diabetic sensory neuropathy and LOPS.
There is one hard rule on frequency that catches billing teams off guard: if the patient saw a foot care specialist for any other reason between exams, the six-month coverage resets. Medicare will not cover the exam under NCD 171 if that interim visit occurred. Track this in your scheduling system — a missed flag here is a direct path to claim denial.
LOPS must be diagnosed using sensory testing with the 5.07 Semmes-Weinstein monofilament. The test follows a specific protocol: five sites on the plantar surface of each foot, tested randomly, avoiding heavily callused areas. Randomized testing matters — the policy explicitly requires it because LOPS can be patchy, and rhythmic testing can give the patient positional cues that skew results.
The diagnosis threshold is clear. Absence of sensation at two or more sites out of five on either foot is required to confirm peripheral neuropathy with LOPS. That finding must be documented before coverage applies. No documentation, no medical necessity. That is not an interpretation — that is exactly what the policy states.
Prior authorization is not explicitly required under this NCD, but that does not mean your MAC won't have additional requirements. Check your local coverage determination and MAC-specific billing guidelines before the effective date of March 7, 2026. Some MACs layer additional criteria on top of NCDs, and diabetic foot care has historically been an area where local policies diverge.
What the CMS NCD 171 Exam Must Include — And Why It Matters for Reimbursement
This is where many practices leave money on the table, or worse, expose themselves to post-payment audit risk. The exam under NCD 171 is not a casual foot check. It has defined required components, and documentation must reflect all of them.
The physical examination must include:
- Visual inspection of forefoot and hindfoot, including toe web spaces
- Evaluation of protective sensation
- Evaluation of foot structure and biomechanics
- Evaluation of vascular status and skin integrity
- Evaluation of the need for special footwear
The encounter also requires a patient history and patient education. All three elements — history, physical exam, and education — must be present. Miss one, and you have a documentation gap that can trigger a claim denial on audit.
Treatment under this coverage policy includes local care of superficial wounds, debridement of corns and calluses, and trimming and debridement of nails. The policy states this list is not exhaustive, which gives you some flexibility. But the covered treatments must be tied to the documented diabetic sensory neuropathy diagnosis. Neuropathy billing tied to non-diabetic etiology does not qualify here.
Reimbursement under NCD 171 depends entirely on documentation precision. If your notes don't reflect every required exam element, you're at risk regardless of whether the clinical work was done.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Foot exam (evaluation) for documented diabetic sensory neuropathy with LOPS | Covered | Not specified in policy data | No more than every six months; no interim foot care specialist visit for other reason |
| LOPS diagnosis via 5.07 Semmes-Weinstein monofilament testing — absence of sensation at 2+ of 5 sites on either foot | Covered (required for diagnosis) | Not specified in policy data | Must be documented; five sites tested randomly on plantar surface of each foot |
| Patient history, physical exam (all required elements), and patient education | Covered (required components) | Not specified in policy data | All three components must be present and documented |
| Local care of superficial wounds | Covered (as treatment) | Not specified in policy data | Must be tied to diabetic sensory neuropathy with LOPS diagnosis |
| Debridement of corns and calluses | Covered (as treatment) | Not specified in policy data | Must be tied to diabetic sensory neuropathy with LOPS diagnosis |
| Trimming and debridement of nails | Covered (as treatment) | Not specified in policy data | Must be tied to diabetic sensory neuropathy with LOPS diagnosis |
| Foot exam when patient has seen a foot care specialist for another reason in the interim period | Not Covered | Not specified in policy data | Interim specialist visit for any other reason disqualifies the six-month exam |
| Foot care services not connected to documented diabetic sensory neuropathy with LOPS | Not Covered | Not specified in policy data | General foot care exclusion applies; NCD 171 exception is condition-specific |
CMS Diabetic Peripheral Neuropathy Billing Guidelines and Action Items 2026
These steps are based directly on NCD 171 policy requirements. Work through them before March 7, 2026.
| # | Action Item |
|---|---|
| 1 | Audit your documentation templates now. Your exam notes must capture all required physical exam elements — forefoot and hindfoot inspection, protective sensation evaluation, foot structure and biomechanics, vascular status and skin integrity, and footwear assessment. Add a structured checklist if your current template doesn't prompt for each component. |
| 2 | Verify the LOPS diagnosis is properly documented in the chart. The 5.07 monofilament test result — specifically, the number of sites tested and the number with absent sensation on each foot — must appear in the medical record. "LOPS present" without the monofilament findings is not sufficient for medical necessity under this policy. |
| 3 | Build a six-month interval tracker per beneficiary. The every-six-months limit is per patient, not per calendar year. More importantly, you need to flag whether the patient had any foot care specialist visit for another reason between exams. That interim visit voids coverage for the NCD 171 exam. Your scheduling team needs to ask this question at intake. |
| 4 | Check your MAC's local coverage determination for additional requirements. NCD 171 sets the floor. Your Medicare Administrative Contractor may have a local LCD that adds documentation requirements, frequency restrictions, or modifier requirements on top of the national policy. Don't assume the NCD is the whole picture. |
| 5 | Review diagnosis coding for all diabetic foot exam claims. The covered diagnosis must reflect diabetic sensory neuropathy with LOPS — not general diabetic neuropathy, not peripheral vascular disease, not routine foot care. Confirm your ICD-10-CM coding aligns with the specific condition this policy covers. If you're unsure how your current coding maps to the NCD 171 criteria, loop in your compliance officer before the effective date. |
| 6 | Train your clinical staff on the monofilament testing protocol. Two things fail in practice: testing rhythmically instead of randomly, and testing on callused areas. The policy explicitly prohibits both. If your clinical staff isn't aware of these protocol requirements, a technically sound exam can still produce a flawed test result — and a documented flawed result undermines medical necessity. |
| 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 Diabetic Peripheral Neuropathy Services Under NCD 171
The policy data for NCD 171 does not specify CPT, HCPCS, or ICD-10 codes in the current published version. This is not unusual for older NCDs that predate structured code-level policy data.
For diabetic peripheral neuropathy billing under NCD 171, work with your MAC's claims processing instructions and the CMS transmittals cross-referenced in this policy — specifically TN AB-02-158, TN AB-02-096, TN AB-02-109, and TN A-02-039. Those transmittals contain the claims processing guidance tied to this coverage policy.
Your coding team should confirm the appropriate evaluation and management codes, procedure codes for debridement and nail care, and ICD-10-CM codes for diabetic sensory neuropathy with LOPS against your MAC's current billing guidelines. If your MAC has published a corresponding LCD for diabetic foot care, that document will contain the code-level specificity that NCD 171 itself does not.
This is an area where the absence of published codes in the NCD creates real exposure. If your billing team isn't cross-referencing the MAC transmittals, you're working without the full picture. Talk to your billing consultant if you need help mapping current codes to the NCD 171 criteria.
Get the Full Picture
Track this policy across versions, search 1,500+ policies by CPT code, and get real-time alerts when any payer changes coverage.