CMS Modified NCD 191 for Esophageal Manometry, Effective March 7, 2026 — Here's What Billing Teams Need to Know
TL;DR: The Centers for Medicare & Medicaid Services modified NCD 191, the National Coverage Determination governing Medicare esophageal manometry coverage, effective March 7, 2026. The policy retains its "reasonable and necessary" standard, but billing teams should audit documentation practices now — this change creates real exposure if medical necessity isn't airtight in the record.
NCD 191 in the CMS Medicare system covers esophageal manometry — a diagnostic procedure measuring esophageal pressure used to identify conditions like achalasia, aperistalsis, scleroderma, and esophageal spasm. The policy does not list specific CPT or HCPCS codes. That gap matters for billing teams, and we'll cover exactly what to do about it below.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Esophageal Manometry — NCD 191 |
| Policy Code | NCD 191 |
| Change Type | Modified |
| Effective Date | 2026-03-07 |
| Impact Level | Medium |
| Specialties Affected | Gastroenterology, General Surgery, Internal Medicine, Thoracic Surgery |
| Key Action | Confirm all esophageal manometry claims include documentation of medical necessity tied to a specific esophageal diagnosis before submitting to Medicare |
CMS Esophageal Manometry Coverage Criteria and Medical Necessity Requirements 2026
The CMS esophageal manometry coverage policy is built on a single governing standard: the procedure must be "reasonable and necessary for the individual patient." That phrase does a lot of work. It means blanket orders won't hold up. Routine or screening use won't hold up either.
Medical necessity for esophageal manometry under NCD 191 centers on difficult diagnostic cases. The policy specifically positions this procedure as a tool for cases where X-rays and endoscopy haven't resolved the clinical question. If your documentation doesn't establish that context — that prior imaging or direct visualization was insufficient or incomplete — you're building the claim on a shaky foundation.
The clinical scope of this coverage policy is wide. CMS recognizes esophageal manometry for diagnosing aperistalsis, esophageal spasm, achalasia, esophagitis, esophageal ulcer, esophageal congenital webs, diverticuli, scleroderma, hiatus hernia, congenital cysts, benign and malignant tumors, esophageal hypermobility, esophageal hypomobility, and extrinsic lesions. That's a long list — but don't let it give you false confidence. Coverage is tied to patient-specific medical necessity, not to the diagnosis code alone.
NCD 191 does not mention prior authorization requirements at the national level. That doesn't mean your Medicare Administrative Contractor won't have one. Check with your regional MAC — some have local coverage determinations (LCDs) that layer additional requirements on top of the NCD. If you're not sure whether your MAC has an LCD for esophageal manometry, look it up before the effective date of March 7, 2026.
Reimbursement is also not addressed in NCD 191 itself. The national policy sets coverage rules; fee schedule amounts are set separately. If you're trying to model the financial impact on your practice, pull the current Medicare Physician Fee Schedule for the relevant procedure codes — not this NCD.
Coverage Indications at a Glance
The policy summary identifies a range of esophageal conditions for which manometry is recognized as a diagnostic tool. All are subject to the individual patient "reasonable and necessary" standard.
| Indication | Coverage Status | Relevant Codes | Notes |
|---|---|---|---|
| Aperistalsis | Covered (when medically necessary) | Not specified in NCD 191 | Must document failed or insufficient prior workup |
| Esophageal spasm | Covered (when medically necessary) | Not specified in NCD 191 | Difficult diagnostic cases; adjunct to X-ray or endoscopy |
| Achalasia | Covered (when medically necessary) | Not specified in NCD 191 | Standard diagnostic use recognized |
| Esophagitis | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Esophageal ulcer | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Esophageal congenital webs | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Diverticuli | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Scleroderma | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Hiatus hernia | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Congenital cysts | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Benign and malignant tumors | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Esophageal hypermobility | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Esophageal hypomobility | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Extrinsic lesions | Covered (when medically necessary) | Not specified in NCD 191 | Must meet individual necessity standard |
| Screening or routine use | Not covered | — | Policy positions manometry as adjunct tool for difficult cases |
CMS Esophageal Manometry Billing Guidelines and Action Items 2026
Here's what your billing team and revenue cycle staff should do before and after March 7, 2026.
| # | Action Item |
|---|---|
| 1 | Audit your medical necessity documentation now. Pull a sample of recent esophageal manometry claims from the past 90 days. Check whether each one documents why X-rays or endoscopy were insufficient to reach a diagnosis. That clinical rationale is the core of what NCD 191 requires. If it's missing, your claim denial risk is real. |
| 2 | Confirm which CPT codes your practice uses for esophageal manometry billing — and whether your MAC has a local coverage determination. NCD 191 does not list specific CPT or HCPCS codes. Your MAC's LCD, if one exists for this procedure, will. Contact your MAC or check the CMS LCD database to confirm any local billing guidelines that apply to your region. |
| 3 | Review your ordering providers' documentation templates. Medical necessity lives in the clinical note, not just the order. If your physicians are ordering esophageal manometry without documenting the diagnostic dilemma that warrants it — or without noting prior workup results — fix the template before March 7, 2026. |
| 4 | Don't assume a covered diagnosis code is enough. A claim with achalasia as the diagnosis is not automatically a covered claim. NCD 191 requires patient-specific medical necessity. That means the record needs to tell the story of why this patient, with this presentation, needed this test at this time. |
| 5 | Verify there are no prior authorization requirements through your MAC. NCD 191 is silent on prior authorization at the national level. That's not a green light — it's a gap. Some MACs add authorization requirements through LCDs or contractor policies. Confirm before submitting. |
| 6 | If you're unsure how this change affects your claim volume or payer mix, talk to your compliance officer before the effective date. The "reasonable and necessary" standard sounds simple, but it has generated significant claim denial activity across procedures that use the same language. Don't assume your current process is compliant without checking. |
| 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 Esophageal Manometry Under NCD 191
CPT and HCPCS Codes
NCD 191 does not list specific CPT or HCPCS codes. The policy does not provide procedure-level code assignments.
This is a real problem for esophageal manometry billing. You need to identify the correct CPT codes through your MAC's LCD or through CMS claims processing instructions — the NCD alone won't get you there. Work with your coding team to confirm the correct codes are on file.
| Code | Type | Description |
|---|---|---|
| Not specified in NCD 191 | — | CMS does not list specific codes in this NCD. Consult your MAC's LCD and CMS claims processing instructions. |
ICD-10-CM Diagnosis Codes
NCD 191 does not list specific ICD-10-CM codes. The policy describes covered diagnoses in clinical language — not in code sets. Your coding team should map the covered conditions (achalasia, aperistalsis, scleroderma, esophageal spasm, etc.) to the appropriate ICD-10-CM codes using the current code set.
| Code | Description |
|---|---|
| Not specified in NCD 191 | Map covered conditions to ICD-10-CM using the diagnoses listed in the policy: achalasia, aperistalsis, esophageal spasm, esophagitis, esophageal ulcer, congenital webs, diverticuli, scleroderma, hiatus hernia, congenital cysts, benign and malignant tumors, hypermobility, hypomobility, and extrinsic lesions |
The absence of codes in this NCD is not unusual for older national coverage determinations. But it does mean your billing guidelines can't lean on NCD 191 alone. You need your MAC's LCD to complete the picture.
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