US · guidance
CMS Pub. 100-04, ch. 32, § 66.1
Institutional Billing for National Coverage Determination (NCDs) services that are
considered a significant cost for Medicare Advantage
(Rev. 10229, Issued: 07-21-20 Effective: 10-01-20, Implementation: 10-05-20)
A. Institutional Inpatient Billing for National Coverage Determination (NCDs) services that are considered a
significant cost for Medicare Advantage.
The Medicare contractors shall allow Condition Code (CC) 78 on any inpatient institutional claims for Medicare
Advantage beneficiaries when it is determined that certain services are being disallowed on MA plans that are
considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Any current
editing that doesn’t allow this shall be updated to allow this scenario, unless there has been previous instructions
excluding certain conditions.
Note: Condition Code 78 = Newly covered Medicare service for which an HMO doesn't pay.
B. Institutional Outpatient Billing for National Coverage Determination (NCDs) services that are considered a
significant cost for Medicare Advantage
The Medicare contractors shall allow Condition Code (CC) 78 on any outpatient institutional claims for Medicare
Advantage beneficiaries when it is determined that certain services are being disallowed on MA plans that are
considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Any current
editing that doesn’t allow this shall be updated to allow this scenario, unless there has been previous instructions
excluding certain conditions.
Note: Condition Code 78 = Newly covered Medicare service for which an HMO doesn't pay.
History
(Rev. 10229, Issued: 07-21-20 Effective: 10-01-20, Implementation: 10-05-20)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
2b6feb11b15d1aa603e8a8150d00d02bee847a9c631dbca93d55fbc54dc37b43
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