CMS modified NCD 263 governing ultrasound diagnostic procedures, effective January 9, 2026. Here's what billing teams need to know.
The Centers for Medicare & Medicaid Services updated its ultrasound diagnostic procedures coverage policy under National Coverage Determination NCD 263. This modification clarifies which ultrasound procedures Medicare covers, which it considers experimental, and where your MAC has discretion in medical necessity review. The policy does not list specific CPT or HCPCS codes in the updated document, so your team will need to map procedures to codes using your current code set. This affects billing across radiology, cardiology, obstetrics, vascular surgery, and several other specialties.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Ultrasound Diagnostic Procedures |
| Policy Code | NCD 263 |
| Change Type | Modified |
| Effective Date | January 9, 2026 |
| Impact Level | High |
| Specialties Affected | Radiology, Cardiology, Obstetrics/Gynecology, Vascular Surgery, Urology, Oncology, Endocrinology, Pulmonology |
| Key Action | Audit all ultrasound procedure billing against the updated Category I and Category II designations before January 9, 2026 |
CMS Ultrasound Coverage Criteria and Medical Necessity Requirements 2026
The core structure of this coverage policy hasn't changed, but the modification makes the framework official for 2026 Medicare billing. CMS divides ultrasound procedures into two categories, and that distinction is everything when it comes to reimbursement.
Category I procedures are covered. CMS describes these as clinically effective, usually part of the initial patient evaluation, and sometimes used as an adjunct to radiologic and nuclear medicine diagnostic techniques. Medical necessity for Category I procedures hinges on appropriate clinical indication and proper documentation.
Category II procedures are considered experimental. Medicare will not cover them at this time. If your team bills any Category II procedure, expect a claim denial.
The coverage policy also requires your Medicare Administrative Contractor — your MAC — to conduct periodic claims review. MAC medical consultants check whether techniques are medically appropriate and whether general indications are met. This means medical necessity documentation isn't just a best practice here. It's a direct policy requirement. Your clinical staff need to know that MAC review is explicitly built into this NCD.
Prior authorization is not specifically required under NCD 263, but that doesn't reduce your documentation burden. MAC-level scrutiny of medical necessity means your notes need to justify every scan. If you're billing ultrasound across high-volume specialties — cardiology, OB, vascular — treat each claim as if it could be pulled for review. Because it can be.
Whether a specific procedure falls under a local coverage determination from your MAC, or is governed solely by this NCD, depends on your region. Check with your MAC for any supplemental LCD that applies to ultrasound billing in your jurisdiction.
CMS Ultrasound Exclusions and Non-Covered Indications
CMS is direct about Category II: experimental procedures don't get covered. The NCD doesn't list every Category II procedure in the portion of the document provided, but the exclusion framework is clear. Anything CMS designates as experimental in NCD 263 is off the table for Medicare billing.
Beyond the Category I / Category II split, several specific limitations are worth noting.
Abdominal sonography is explicitly not synonymous with ultrasound examination of individual organs. If you're billing a complete abdominal sonography, you can't also stack individual organ scans on the same claim and expect them to pass review.
Retroperitoneal sonography does not include planning of fields for radiation therapy. If your oncology team uses ultrasound for radiation field planning, that's a separate service — not bundled into the retroperitoneal sonography indication.
Urinary bladder sonography does not include staging of bladder tumors. Staging requires a different clinical and billing approach.
These carve-outs matter because they're the kind of nuance that drives claim denial in high-volume practices. A billing team that treats "complete abdominal sonography" as a catch-all for multiple organ studies is going to get burned on audit.
Coverage Indications at a Glance
The following table maps the clinical indications listed in NCD 263 to their coverage status. NCD 263 does not list specific CPT codes in the updated document, so code mapping is your team's responsibility.
| Indication | Status | Notes |
|---|---|---|
| Echoencephalography, Diencephalic Midline (A-Mode) | Covered | Category I |
| Echoencephalography, Complete (A-Mode) | Covered | Category I |
| Ocular and Orbital Echography (A-Mode) | Covered | Category I; includes lens implant suitability assessment post-cataract surgery |
| Ocular and Orbital Sonography (B-Mode) | Covered | Category I |
| Echocardiography, Pericardial Effusion (M-Mode) | Covered | Category I |
| Pericardiocentesis, by Ultrasonic Guidance | Covered | Category I |
| Echocardiography, Cardiac Valve(s) (M-Mode) | Covered | Category I |
| Echocardiography, Complete (M-Mode) | Covered | Category I |
| Echocardiography, Limited (M-Mode) | Covered | Category I; e.g., follow-up or limited study |
| Pleural Effusion Echography | Covered | Category I |
| Thoracentesis, by Ultrasonic Guidance | Covered | Category I |
| Abdominal Sonography, Complete (B-Scan) | Covered | Category I; not synonymous with individual organ exams |
| Abdominal Sonography, Limited (B-Scan) | Covered | Category I; e.g., follow-up or limited study |
| Renal Cyst Aspiration, by Ultrasonic Guidance | Covered | Category I |
| Renal Biopsy, by Ultrasonic Guidance | Covered | Category I |
| Pancreas Sonography (B-Scan) | Covered | Category I; proven effective for pseudocyst diagnosis |
| Spleen Sonography (B-Scan) | Covered | Category I |
| Abdominal Aorta Echography (A-Mode) | Covered | Category I |
| Abdominal Aorta Sonography (B-Scan) | Covered | Category I |
| Retroperitoneal Sonography (B-Scan) | Covered | Category I; excludes radiation therapy field planning |
| Urinary Bladder Sonography (B-Scan) | Covered | Category I; excludes staging of bladder tumors |
| Pregnancy Diagnosis Sonography (B-Scan) | Covered | Category I |
| Fetal Age Determination — Biparietal Diameter (B-Scan) | Covered | Category I |
| Fetal Growth Rate Sonography (B-Scan) | Covered | Category I |
| Placenta Localization Sonography (B-Scan) | Covered | Category I |
| Pregnancy Sonography, Complete (B-Scan) | Covered | Category I |
| Molar Pregnancy Diagnosis Sonography (B-Scan) | Covered | Category I |
| Ectopic Pregnancy Diagnosis Sonography (B-Scan) | Covered | Category I |
| Passive Testing (Antepartum Fetal Heart Rate Monitoring) | Covered | Category I |
| Intrauterine Contraceptive Device Sonography (B-Scan) | Covered | Category I |
| Pelvic Mass Diagnosis Sonography (B-Scan) | Covered | Category I |
| Amniocentesis, by Ultrasonic Guidance | Covered | Category I |
| Arterial Flow Study, Peripheral (Doppler) | Covered | Category I |
| Venous Flow Study, Peripheral (Doppler) | Covered | Category I |
| Arterial Aneurysm, Peripheral (B-Scan) | Covered | Category I |
| Radiation Therapy Planning Sonography (B-Scan) | Covered | Category I |
| Thyroid Echography (A-Mode) | Covered | Category I |
| Thyroid Sonography (B-Scan) | Covered | Category I |
| Breast Echography (A-Mode) | Covered | Category I |
| Breast Sonography (B-Scan) | Covered | Category I |
| Hepatic Sonography (B-Scan) | Covered | Category I |
| Gallbladder Sonography | Covered | Category I |
| Renal Sonography | Covered | Category I |
| Two-Dimensional Echocardiography (B-Mode) | Covered | Category I |
| Monitoring of Cardiac Output — Esophageal Doppler (ventilated patients) | Covered | Category I |
| Category II Procedures | Not Covered | Considered experimental; claim denial expected |
CMS Ultrasound Billing Guidelines and Action Items 2026
This is where you need to act. The effective date is January 9, 2026. If you haven't already, these steps need to happen now.
| # | Action Item |
|---|---|
| 1 | Map every ultrasound indication in your charge master to the Category I list. NCD 263 does not publish specific CPT or HCPCS codes. Your billing team owns the code-to-indication mapping. If a procedure your practice performs is not on the Category I list, it is either Category II (not covered) or falls outside this NCD entirely. Know which before January 9, 2026. |
| 2 | Audit your abdominal sonography billing for improper bundling. CMS is explicit: abdominal sonography is not a catch-all for individual organ studies. Pull your last 90 days of abdominal ultrasound claims. Check whether individual organ scans are being billed alongside complete or limited abdominal sonography on the same date of service. |
| 3 | Flag retroperitoneal and bladder sonography claims for documentation review. Retroperitoneal sonography excludes radiation therapy field planning. Bladder sonography excludes tumor staging. If your urology or oncology teams use these codes, confirm that documentation supports the covered indication — not the excluded one. |
| 4 | Brief your MAC on any questions about local coverage. NCD 263 operates at the national level, but your MAC conducts the actual periodic medical necessity reviews. If you're in a high-volume ultrasound specialty, talk to your MAC contact about what their consultants flag most often on these claims. A local coverage determination may also apply to your jurisdiction. |
| 5 | Update your medical necessity documentation templates before January 9, 2026. Every Category I procedure needs a defensible clinical indication in the chart. MAC reviewers check this. Build templates that prompt your clinicians to document the specific indication — not just "ultrasound ordered." If your EHR uses order sets, update them to capture indication language that maps to Category I criteria. |
| 6 | Train your billing team on experimental category denials. If your practice has ever billed — or suspects it may have billed — Category II procedures to Medicare, pull those claims now. A pattern of experimental procedure billing is exactly what MAC medical consultants look for during periodic review. Address it proactively, not in response to a pre-payment audit. |
| 7 | If you bill esophageal Doppler monitoring for cardiac output in ventilated patients, confirm your charge capture reflects the covered indication. This is a specific, narrow indication. The policy covers it for ventilated patients only. If your team uses this in other contexts, the claim will not survive review. |
If your practice spans multiple high-volume ultrasound specialties — cardiology, OB, vascular, radiology — and you're not sure how this NCD interacts with your existing billing guidelines, talk to your compliance officer before January 9, 2026.
| 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 Ultrasound Diagnostic Procedures Under NCD 263
No Codes Listed in Updated Policy Document
NCD 263 as modified on January 9, 2026 does not include a specific list of CPT, HCPCS, or ICD-10 codes in the published document. This is a known limitation of how CMS has structured this particular NCD.
Your ultrasound billing team needs to map the clinical indications listed in Category I to the appropriate CPT codes using the current AMA CPT code set. Common ultrasound CPT codes your team likely already uses — such as those covering echocardiography, obstetric sonography, abdominal sonography, vascular Doppler studies, and guidance procedures — should be cross-referenced against the Category I indication list.
Do not assume a CPT code's existence in your charge master means it's covered under NCD 263. Coverage depends on the indication, not just the code. If your compliance officer or billing consultant needs to validate your code-to-indication mapping against the full policy, the source document is available at https://app.payerpolicy.org/p/cms/263-v3.
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