Blood Counts — NCD 61 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 61, the National Coverage Determination governing Medicare blood count coverage, effective January 9, 2026. Here's what billing teams need to know.

This update to the CMS blood counts coverage policy clarifies the full scope of indications for complete blood counts (CBCs) and hemograms under Medicare. The policy does not list specific CPT or HCPCS codes — more on what that means for your blood counts billing below.

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Quick-Reference Table

Field	Detail Copy
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	Blood Counts — NCD 61
Policy Code	NCD 61
Change Type	Modified
Effective Date	2026-01-09
Impact Level	Medium
Specialties Affected	Internal Medicine, Hematology/Oncology, Primary Care, Family Medicine, Hospital Outpatient, Clinical Laboratory
Key Action	Audit your CBC and hemogram medical necessity documentation against the updated indication list before January 9, 2026

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CMS Blood Count Coverage Criteria and Medical Necessity Requirements 2026

NCD 61 is the National Coverage Determination that governs whether Medicare covers blood counts — specifically the complete blood count (CBC) and the hemogram — as diagnostic laboratory tests. CMS modified this coverage policy on January 9, 2026. The effective date matters because claims for CBCs and hemograms billed to Medicare must align with the updated criteria from that date forward.

The CBC includes two main components. First, the hemogram: enumeration of red blood cells (RBCs), white blood cells (WBCs), and platelets, plus hemoglobin, hematocrit, and red cell indices. Second, the differential white blood count. These measurements are typically run together on a multichannel analyzer, which is why the CBC is one of the most commonly ordered lab tests in Medicare.

The real issue here is medical necessity documentation. Because the CBC is so routine, billing teams often treat it as automatic. It isn't. CMS requires that each claim tie back to a covered indication — a sign, symptom, test result, illness, or disease that justifies the test. If your documentation doesn't connect the order to a covered indication, you're exposed to claim denial.

What CMS Covers Under NCD 61

CMS covers CBCs and hemograms across three broad clinical categories. Each category has its own list of qualifying indications.

Category 1 — Bone Marrow and Systemic Disorders

CMS covers the CBC for evaluation of bone marrow dysfunction from neoplasms, therapeutic agents, toxic substance exposure, or pregnancy. Coverage also applies when there is suspected bone marrow failure or infiltrate, suspected myeloproliferative or myelodysplastic processes, suspected lymphoproliferative processes, peripheral destruction of blood cells, and immune disorders.

Category 2 — Red Cell (RBC) Parameters: Anemia and RBC Disorders

This is the longest indication list in the policy. CMS covers the CBC or hemogram when a patient shows signs, symptoms, test results, illness, or disease associated with anemia or another RBC disorder. The list includes: pallor, weakness, fatigue, weight loss, bleeding, acute injury with blood loss or suspected blood loss, abnormal menstrual bleeding, hematuria, hematemesis, hematochezia, positive fecal occult blood test, malnutrition, vitamin deficiency, malabsorption, neuropathy, known malignancy, acute or chronic disease with possible associated anemia, coagulation or hemostatic disorders, postural dizziness, syncope, abdominal pain, change in bowel habits, chronic marrow hypoplasia or decreased RBC production, tachycardia, systolic heart murmur, congestive heart failure, dyspnea, angina, nailbed deformities, growth retardation, jaundice, hepatomegaly, splenomegaly, lymphadenopathy, and lower extremity ulcers.

That's a long list. The point is not to memorize it — it's to make sure your providers are documenting one of these indications when they order a CBC for RBC evaluation.

Category 3 — Red Cell (RBC) Parameters: Polycythemia

CMS also covers the CBC or hemogram when polycythemia is suspected. Covered indications include fever, chills, ruddy skin, conjunctival redness, cough, wheezing, cyanosis, finger clubbing, orthopnea, heart murmur, headache, cognitive changes (including memory changes), sleep apnea, weakness, pruritus, dizziness, excessive sweating, visual symptoms, weight loss, massive obesity, gastrointestinal bleeding, paresthesias, dyspnea, joint symptoms, and epigastric symptoms.

Category 4 — White Cell (WBC) Parameters

Coverage extends to WBC-related indications. These include infections, inflammatory disorders, immunosuppression, neoplasms affecting WBC production or function, toxic substance exposure affecting WBCs, and treatments that affect white cell counts — including chemotherapy and immunosuppressive agents.

Category 5 — Platelet Parameters

CMS covers the CBC for evaluation of platelet abnormalities including thrombocytopenia and thrombocytosis. Covered indications include bleeding disorders, coagulopathies, conditions causing platelet destruction or sequestration, and therapies known to affect platelet counts.

Monitoring Use

Beyond diagnosis, CMS explicitly covers blood counts to monitor treatment effects. If a patient is on a medication or therapy known to affect the blood or bone marrow, ongoing CBC monitoring is a covered use. This is particularly relevant for oncology, rheumatology, and any practice managing patients on long-term immunosuppressive or cytotoxic therapy.

Prior Authorization and Reimbursement

NCD 61 does not require prior authorization for blood counts under Medicare. Coverage is based on meeting the medical necessity criteria at the time of the order. However, your Medicare Administrative Contractor (MAC) may have local coverage determinations (LCDs) that layer additional documentation requirements on top of this NCD. Check your MAC's LCD library — this NCD sets the floor, not necessarily the ceiling.

Reimbursement for CBCs and hemograms flows through the Clinical Laboratory Fee Schedule. The rate depends on the specific CPT code billed, which the NCD itself does not specify (more on codes below).

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Coverage Indications at a Glance

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CMS Blood Counts Billing Guidelines and Action Items 2026

The policy modification is live as of January 9, 2026. Here's what to do now.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Blood Counts Under NCD 61

Specific Codes Listed in Policy Data

NCD 61 as modified does not list specific CPT, HCPCS, or ICD-10 codes. This is intentional — the NCD governs medical necessity criteria for blood counts broadly, and the applicable CPT codes are mapped at the claim level based on the specific test performed.

Your blood counts billing team should use the appropriate CPT codes from the Pathology and Laboratory section of the CPT code set. Common codes in this category include CBC with and without differential, hemogram, and automated WBC differential — but confirm your code selection with your lab billing team or coding consultant based on your equipment and test methodology.

For ICD-10-CM diagnosis codes, select the code that best reflects the covered indication documented in the medical record. The indication categories in NCD 61 map to a wide range of ICD-10 codes across the D (Blood) chapter, the C (Neoplasms) chapter, and condition-specific codes in other chapters. Your compliance officer or coding team should maintain a crosswalk from covered indications to your commonly used ICD-10 codes for CBC orders.

If you are unsure how your specific code mix maps to NCD 61 coverage criteria, talk to your billing consultant before the January 9, 2026 effective date. The absence of explicit codes in this NCD makes it easy to assume everything is covered — and that assumption is what drives unnecessary claim denials.

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