Endothelial Cell Photography — NCD 213 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 213 governing Medicare coverage of endothelial cell photography, effective March 7, 2026. Here's what billing teams need to know before claims go out.

CMS updated NCD 213—the National Coverage Determination governing Medicare reimbursement for endothelial cell photography performed via specular microscopy—with a modification effective 2026-03-07. The policy covers ophthalmology practices billing for this diagnostic procedure, which measures corneal endothelial cell counts as part of pre-surgical or diagnostic workups. The policy document does not list specific CPT or HCPCS codes, so your billing team will need to verify applicable procedure codes against your current charge master before the effective date.

Quick-Reference Table

CMS Endothelial Cell Photography Coverage Criteria and Medical Necessity Requirements 2026

The core rule under NCD 213 is this: endothelial cell photography is a covered Medicare benefit when it is reasonable and necessary, and a patient meets at least one of seven specific clinical indications. That's not unusual for a CMS coverage policy, but the combination exam bundling rule buried in the middle of this policy is where billing teams get burned—and it deserves more attention than it typically gets.

CMS will cover endothelial cell photography for patients who meet one or more of the following criteria:

That seventh indication—extended wear contact lens fitting after intraocular surgery—gets overlooked in practice. If your ophthalmology team is managing post-surgical contact lens patients under Medicare, document that indication explicitly in the chart before billing.

The reimbursement question here isn't just whether the procedure is covered—it's whether you're billing it as a standalone or as part of a bundled pre-surgical exam. Get that distinction wrong and you're looking at a claim denial or a recoupment.

The policy does not reference prior authorization requirements for this service. That's consistent with how CMS typically handles diagnostic tests under the diagnostic tests benefit category. But medical necessity documentation—specifically slit lamp findings and the clinical rationale tying the exam to one of the seven indications—is non-negotiable for audit defense.

CMS Endothelial Cell Photography Exclusions and Non-Covered Indications

NCD 213 doesn't include a broad "not covered" designation, but there is one meaningful carve-out worth flagging.

Refractive surgery procedures excluded under §80.7 of the Medicare Coverage Database are explicitly called out as outside the coverage boundary for this policy. If a patient is undergoing a refractive procedure that falls under that exclusion list, endothelial cell photography performed in that context is not covered under NCD 213, even if the procedure itself involves elevated risk to the corneal endothelium.

Check §80.7 directly if your practice performs refractive procedures. Don't assume phacoemulsification and refractive surgery are interchangeable for billing purposes here—they're not.

Coverage Indications at a Glance

That last row is the one that generates claim denials. Read it carefully.

CMS Endothelial Cell Photography Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Endothelial Cell Photography Under NCD 213

Applicable Procedure Codes

The policy document for NCD 213 does not enumerate specific CPT or HCPCS codes. CMS has not published a code list within this NCD.

Your billing team should identify the applicable procedure code(s) from your current charge master or encoder, confirm they map to this NCD in your billing system, and verify against the Medicare Coverage Database for any associated Local Coverage Determinations (LCDs) or billing instructions that may specify codes at the MAC level. MAC-level guidance often fills in the code-level detail that NCDs leave blank—check with your MAC's website or your billing consultant if you're not sure what code your region expects.

Key ICD-10-CM Diagnosis Codes to Support Medical Necessity

No ICD-10-CM codes are enumerated in the NCD 213 policy document. The diagnosis codes your billers submit should directly correspond to the covered indications listed in the policy—cornea guttata, corneal edema, posterior polymorphous dystrophy, ICE syndrome, and similar corneal conditions. Work with your ophthalmology coders to confirm the ICD-10-CM codes your practice uses align with the clinical language in the policy's seven covered indications.

If your coding team isn't sure which ICD-10-CM codes map cleanly to each indication, this is worth a targeted review session before March 7, 2026.