What are the codes covered by Medicare?

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Medicare does not have a single fixed list of covered codes; instead, coverage depends on whether a specific CPT/HCPCS procedure code aligns with an approved ICD-10 diagnosis code under national and local guidelines.

📅 How Medicare Codes Work

  • CPT Codes (Level I): 5-character numeric codes for physician and medical services.
  • HCPCS Codes (Level II): Alphanumeric codes for supplies, equipment, and injections.
  • ICD-10 Codes: Diagnosis codes proving the medical necessity of the service.

💡 Finding Specific Covered Codes

  • Use the official Medicare Coverage Database to look up individual procedure codes.
  • Review Local Coverage Determinations (LCDs) provided by your regional Medicare Administrative Contractor (MAC).
  • Check specific billing guidelines from regional contractors like WPS, NGS, or Novitas.

What codes are not reported by Medicare?

S codes are national HCPCS Level II codes that are not reported or paid by Medicare.

Key Details on Non-Medicare Codes

  • S codes: Used by commercial health plans (such as Blue Cross Blue Shield) and state Medicaid agencies to report drugs, services, and supplies when no specific national code exists. Medicare does not recognize or reimburse them.
  • T codes: Used by state Medicaid agencies to report specific services, but they are also not covered or reported by Medicare.
  • Unlisted/Not Otherwise Classified (NOC) codes: While Medicare does accept unlisted or miscellaneous codes when a specific code doesn't exist, they will deny them if a valid, specific HCPCS code is already available.

What are the 6 things Medicare doesn't cover?

Original Medicare (Parts A and B) does not cover several major healthcare needs, most notably routine dental care, eye exams and glasses, hearing aids, long-term custodial care, care outside the U.S., and cosmetic surgery.

Key Uncovered Services

  • Routine Dental Care: Original Medicare excludes routine cleanings, fillings, tooth extractions, root canals, and dentures.
  • Vision Care: Routine eye exams, eyeglasses, and contact lenses are not covered, except for specific post-cataract surgery needs or certain diabetic eye exams.
  • Hearing Aids: Routine hearing exams, fittings, and hearing aids are completely excluded from standard coverage.
  • Long-Term Care: Medicare pays for short-term skilled nursing, but it does not cover ongoing custodial care (help with daily activities like bathing, dressing, or eating) in a nursing home or at home.
  • Care Outside the U.S.: Medical treatment received while traveling or living abroad is generally not covered.
  • Cosmetic Surgery: Elective procedures meant to alter appearance rather than treat a specific illness or injury are excluded.

You can review the official breakdown of excluded services directly on the Official Medicare Coverage Guide.

How do I get a list of CPT codes?

You can get an official and complete list of CPT codes by ordering the current codebook through the American Medical Association Store.

Current Procedural Terminology (CPT) codes are a standardized 5-digit medical code set owned, maintained, and copyrighted by the American Medical Association (AMA). Because they are copyrighted intellectual property, a single free, public, and complete master list of all 11,000+ codes does not exist in one official government document.

How to Access CPT Codes

  • Official Books and Digital Data: Purchase the official CPT Professional Edition book, eBook, or data file licenses directly from the American Medical Association Store.
  • Online Coding Tools: Use professional medical billing and coding databases like Codify by AAPC to search and filter codes.
  • Government & Specialized Lists:
    • The Centers for Medicare & Medicaid Services (CMS) provides a List of CPT/HCPCS Codes specifically for designated health services and physician self-referral exceptions.
    • CMS also offers free tools like the Relative Value Unit (RVU) search to look up individual code valuations.

Can you provide a list of medical coding codes?

You can search and look up comprehensive code sets using the AAPC Code Search tool.

Medical coding uses three main classification systems to record patient diagnoses and medical services. Because there are tens of thousands of individual codes, they are organized into structured numerical and alphabetical ranges rather than a single short list.

Current Procedural Terminology (CPT) Codes

CPT codes are five-digit numbers that describe medical, surgical, and diagnostic services. They are managed by the American Medical Association.

  • 99202–99499: Evaluation and Management (office visits and check-ups)
  • 00100–01999: Anesthesia services
  • 10004–69990: Surgery procedures
  • 70010–79999: Radiology and imaging procedures
  • 80047–89398: Pathology and laboratory tests
  • 90281–99607: Medicine services and procedures

International Classification of Diseases (ICD-10) Codes

ICD-10 codes use three to seven alphanumeric characters starting with a letter. They explain the patient's diagnosis and medical necessity.

  • A00–B99: Infectious and parasitic diseases
  • C00–D49: Neoplasms (cancers and tumors)
  • E00–E89: Endocrine, nutritional, and metabolic diseases
  • I00–I99: Diseases of the circulatory system
  • Z00–Z99: Factors influencing health status and contact with health services

Healthcare Common Procedure Coding System (HCPCS Level II) Codes

HCPCS codes cover supplies, equipment, and services not defined in standard CPT codes. They start with a letter followed by four numbers.

  • A0021–A0999: Transportation and ambulance services
  • A4100–A8006: Medical supplies
  • E0100–E8002: Durable medical equipment
  • J0013–J9999: Drugs administered other than oral method
  • L0112–L9900: Orthotic and prosthetic procedures

Medicare Part A B C D Explained (and made simple!)

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How to find out if a CPT code is covered by insurance?

To find out if a specific Current Procedural Terminology (CPT) code is covered by an insurance plan, you must check directly with the payer or use an official lookup tool.

Steps to Check CPT Code Coverage

  • Contact Member Services: Call the toll-free phone number on the back of the patient's insurance card. Provide the representative with the 5-digit CPT code and the matching ICD-10 diagnosis code. Ask if the service is a covered benefit, whether prior authorization is needed, and what the copay or deductible requirements are.
  • Use the Insurer’s Online Portal: Log into the provider or member portal for that specific insurance company (such as Aetna Precertification Lists or commercial payer lookups) to search their specific fee schedules or prior authorization lists.
  • Check Medicare Guidelines: If the patient has Medicare, look up the code on the Medicare Coverage Database to review Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs). You can also review payment rates using the PFS Look-up Tool.
  • Ask the Billing Department: Consult your internal billing software, electronic health record (EHR) system, or coding resources like Codify by AAPC to check code pairings and general compliance guidelines.

Why are S codes not covered by Medicare?

S codes are not covered by Medicare because they are temporary, private-sector codes created for commercial insurers and state Medicaid programs when no official national code exists.

Why Medicare Excludes S Codes

  • Different Purpose: Private insurers and Medicaid requested S codes to track unique drugs, services, and supplies before permanent national codes are issued.
  • Not Recognized by CMS: The Centers for Medicare & Medicaid Services (CMS) does not use or recognize S codes in its national billing system.
  • Invalid for Claims: Medicare treats S codes as invalid codes rather than just non-covered services, meaning claims with these codes are rejected immediately upon receipt.

Instead of S codes, providers must use standard CPT (Level I HCPCS) or permanent Level II HCPCS codes (such as J-codes or G-codes) that Medicare officially accepts for reimbursement.

What is the big mistake people make with Medicare?

The single biggest and most costly mistake people make with Medicare is missing enrollment deadlines, leading to permanent late-enrollment penalties and gaps in coverage.

Missing Enrollment Deadlines

  • Initial Enrollment Period (IEP): This window lasts for seven months. It starts three months before the month you turn 65, includes your birthday month, and ends three months after.
  • Late Penalties: Failing to sign up for Part B or Part D on time can trigger permanent monthly or yearly financial penalties added to your premiums.
  • Delayed Enrollment Confusion: Many people wrongly assume they can delay Medicare past age 65 just because they have health coverage like COBRA, a marketplace plan, or small-employer insurance.

Other Costly Medicare Mistakes

  • Ignoring Annual Changes: Sticking with automatic renewal without reading the Annual Notice of Change (ANOC) can result in unexpected costs, as drug lists and doctor networks shift every year.
  • Choosing Solely by Low Premiums: Picking a plan based only on a low monthly cost while ignoring total out-of-pocket expenses like deductibles, copays, and coinsurance.
  • Missing the Medigap Window: Forgetting to apply for a Medigap (Medicare Supplement) policy during your open enrollment window. After this six-month period, insurers can use medical underwriting to charge more or deny coverage.
  • Skipping Financial Assistance: Overlooking programs like Medicare Savings Programs or Part D Extra Help that assist with out-of-pocket medical and prescription expenses.

What is no longer covered by Medicare?

Original Medicare Original Medicare Not Covered and Medicare Advantage plans have strict rules regarding items and services that are excluded from coverage.

Expiring & Restrictive Coverage Changes

  • Broad Telehealth Flexibilities: Pandemic-era telehealth waivers expired on January 31, 2026 Medicare telehealth flexibilities expire. Beneficiaries generally must be located in a medical facility and in a rural area to receive covered telehealth services, except for behavioral health care Medicare Will No Longer Cover This Popular Service Starting Jan. 31.
  • Medicare Advantage Non-Qualifying Supplemental Items: CMS rules restrict Medicare Advantage plans from covering non-health items previously allowed for chronically ill enrollees, including alcohol, cannabis, tobacco, unhealthy foods, cosmetic procedures (facelifts), funeral costs, and life or hospital indemnity insurance Medicare Advantage Can No Longer Cover These Items in 2026.

Standard Exclusions in Original Medicare

  • Routine Dental Care: Cleanings, fillings, tooth extractions, and dentures What Medicare will not cover in 2026 | The American Legion.
  • Routine Vision Care: Eye exams for prescription glasses, contact lenses, or eyeglasses (except following cataract surgery) What Medicare will not cover in 2026 | The American Legion.
  • Hearing Care: Routine hearing exams and hearing aids What Medicare will not cover in 2026 | The American Legion.
  • Long-Term Custodial Care: Extended nursing home care or assisted living that only involves personal help with daily living activities What Does Medicare Not Cover? Eight Things You Should Know.
  • Routine Foot Care: Cutting corns or calluses and basic toenail clipping What Medicare will not cover in 2026 | The American Legion.
  • Overseas Care: Medical treatment received outside the United States What Medicare will not cover in 2026 | The American Legion, with rare exceptions.

Can I deduct Medicare premiums taken out of my social security check?

Yes, you can deduct Medicare premiums withheld from your Social Security check on your federal income taxes, provided you itemize your deductions and your total medical expenses exceed 7.5% of your adjusted gross income (AGI).

How the Deduction Works

  • Itemizing required: To claim the deduction, you must file Form 1040 and itemize your deductions on Schedule A.
  • The 7.5% threshold: You can only deduct the portion of your total qualified medical expenses (including Medicare Parts A, B, C, D, and Medigap premiums, plus out-of-pocket costs like copays and prescription drugs) that goes over 7.5% of your AGI.
  • Self-employed exception: If you are self-employed and show a net profit, you may qualify for an above-the-line deduction for health insurance premiums without needing to itemize.

Finding Your Total Premiums

  • Form SSA-1099: The Social Security Administration sends you an annual Form SSA-1099. This document lists the exact total of your Medicare premiums that were withheld from your checks over the prior year.