Key facts for NCD 190.25
- Benefit category
- Diagnostic Laboratory Tests
- Effective date
- 11/25/2002
- Implemented 01/01/2003
- Transmittal
- Transmittal 17
- Versions published
- 1
- Manual chapter
- 190
- NCD Manual (Pub. 100-03)
- Lab edit list
- 156 covered ICD-10
- 245 non-covered
TL;DR
NCD 190.25 sets Medicare's national policy for alpha-fetoprotein under the benefit category "Diagnostic Laboratory Tests", effective 11/25/2002 and implemented 01/01/2003. AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology, hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating patients with benign hepatocellular neoplasms… As a laboratory NCD it carries a national ICD-10 edit list: 156 diagnosis codes support medical necessity and 245 are denied, applied automatically by every Medicare contractor to 1 procedure code.
Item or service described
AFP is a polysaccharide found in some carcinomas. It is effective as a biochemical marker for monitoring the response of certain malignancies to therapy.
Indications and limitations of coverage
Indications
AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology, hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating patients with benign hepatocellular neoplasms or metastases from those with hepatocellular carcinoma and, as a non-specific tumor associated antigen, serves in marking germ cell neoplasms of the testis, ovary, retroperitoneum, and mediastinum.
Note: Scroll down for links to the quarterly Covered Code Lists (including narrative).
Text reproduced from the CMS Medicare Coverage Database record for NCD 190.25 version 1. View the original on cms.gov.
Laboratory NCD code lists (January 2026)
Medicare contractors apply this NCD through a national edit: the procedure codes below are paid only when the claim carries a covered diagnosis. The January 2026 list holds 156 covered and 245 non-covered ICD-10-CM codes plus 3 codes with other resolution rules.
1 procedure code are edited against this NCD's diagnosis list. CPT codes are shown as numbers only; descriptors are licensed by the AMA.
| Code | Code set |
|---|---|
| 82105 | CPT (descriptor licensed by AMA) |
The first 40 of 156 covered diagnosis codes, with FY2027 ICD-10-CM descriptions. A claim with any covered code on the line supports medical necessity under the national edit.
| ICD-10-CM | Description | Effective |
|---|---|---|
| A5274 | Syphilis of liver and other viscera | 2015-10-01 |
| B180 | Chronic viral hepatitis B with delta-agent | 2015-10-01 |
| B181 | Chronic viral hepatitis B without delta-agent | 2015-10-01 |
| B182 | Chronic viral hepatitis C | 2015-10-01 |
| B661 | Clonorchiasis | 2015-10-01 |
| B663 | Fascioliasis | 2015-10-01 |
| C220 | Liver cell carcinoma | 2015-10-01 |
| C221 | Intrahepatic bile duct carcinoma | 2015-10-01 |
| C222 | Hepatoblastoma | 2015-10-01 |
| C223 | Angiosarcoma of liver | 2015-10-01 |
| C224 | Other sarcomas of liver | 2015-10-01 |
| C227 | Other specified carcinomas of liver | 2015-10-01 |
| C228 | Malignant neoplasm of liver, primary, unspecified as to type | 2015-10-01 |
| C229 | Malignant neoplasm of liver, not specified as primary or secondary | 2015-10-01 |
| C381 | Malignant neoplasm of anterior mediastinum | 2015-10-01 |
| C382 | Malignant neoplasm of posterior mediastinum | 2015-10-01 |
| C383 | Malignant neoplasm of mediastinum, part unspecified | 2015-10-01 |
| C388 | Malignant neoplasm of overlapping sites of heart, mediastinum and pleura | 2015-10-01 |
| C441321 | Sebaceous cell carcinoma of skin of right upper eyelid, including canthus | 2018-10-01 |
| C441322 | Sebaceous cell carcinoma of skin of right lower eyelid, including canthus | 2018-10-01 |
| C441391 | Sebaceous cell carcinoma of skin of left upper eyelid, including canthus | 2018-10-01 |
| C441392 | Sebaceous cell carcinoma of skin of left lower eyelid, including canthus | 2018-10-01 |
| C561 | Malignant neoplasm of right ovary | 2015-10-01 |
| C562 | Malignant neoplasm of left ovary | 2015-10-01 |
| C563 | Malignant neoplasm of bilateral ovaries | 2021-10-01 |
| C569 | Malignant neoplasm of unspecified ovary | 2015-10-01 |
| C6200 | Malignant neoplasm of unspecified undescended testis | 2015-10-01 |
| C6201 | Malignant neoplasm of undescended right testis | 2015-10-01 |
| C6202 | Malignant neoplasm of undescended left testis | 2015-10-01 |
| C6210 | Malignant neoplasm of unspecified descended testis | 2015-10-01 |
| C6211 | Malignant neoplasm of descended right testis | 2015-10-01 |
| C6212 | Malignant neoplasm of descended left testis | 2015-10-01 |
| C6290 | Malignant neoplasm of unspecified testis, unspecified whether descended or undescended | 2015-10-01 |
| C6291 | Malignant neoplasm of right testis, unspecified whether descended or undescended | 2015-10-01 |
| C6292 | Malignant neoplasm of left testis, unspecified whether descended or undescended | 2015-10-01 |
| C781 | Secondary malignant neoplasm of mediastinum | 2015-10-01 |
| C787 | Secondary malignant neoplasm of liver and intrahepatic bile duct | 2015-10-01 |
| C7960 | Secondary malignant neoplasm of unspecified ovary | 2015-10-01 |
| C7961 | Secondary malignant neoplasm of right ovary | 2015-10-01 |
| C7962 | Secondary malignant neoplasm of left ovary | 2015-10-01 |
245 diagnosis codes deny automatically under this NCD; the first 20 are shown.
| ICD-10-CM | Description |
|---|---|
| R99 | Ill-defined and unknown cause of mortality |
| Z0000 | Encounter for general adult medical examination without abnormal findings |
| Z0001 | Encounter for general adult medical examination with abnormal findings |
| Z00110 | Health examination for newborn under 8 days old |
| Z00111 | Health examination for newborn 8 to 28 days old |
| Z00121 | Encounter for routine child health examination with abnormal findings |
| Z00129 | Encounter for routine child health examination without abnormal findings |
| Z005 | Encounter for examination of potential donor of organ and tissue |
| Z006 | Encounter for examination for normal comparison and control in clinical research program |
| Z0070 | Encounter for examination for period of delayed growth in childhood without abnormal findings |
| Z0071 | Encounter for examination for period of delayed growth in childhood with abnormal findings |
| Z008 | Encounter for other general examination |
| Z020 | Encounter for examination for admission to educational institution |
| Z021 | Encounter for pre-employment examination |
| Z022 | Encounter for examination for admission to residential institution |
| Z023 | Encounter for examination for recruitment to armed forces |
| Z024 | Encounter for examination for driving license |
| Z025 | Encounter for examination for participation in sport |
| Z026 | Encounter for examination for insurance purposes |
| Z0271 | Encounter for disability determination |
Revision history
07/2004 - Published NCD in the NCD Manual without change to narrative contained in PM AB-02-110. Coding guidance now published in Medicare Lab NCD Manual. Effective and Implementation dates NA. ( TN 17 ) (CR 2130)
07/2002 - Implemented NCD. Effective date 11/25/02. Implementation date 1/01/03. ( TN AB-02-110 ) (CR 2130)
How this NCD shows up on remittances
A service denied under a National Coverage Determination returns CARC 50 (not deemed medically necessary) with remark N386 (decision based on an NCD); a denial citing a local policy instead carries N115. Because NCDs bind nationally, the appeal path is documentation that the patient meets the indications above, not a contractor-policy argument.
How QuickIntell applies NCD 190.25
QuickAuth checks the ordered service and diagnosis against NCD and LCD criteria before the encounter, QuickCode validates the diagnosis pairing on the claim, and QuickRCM routes CARC 50 denials with the policy text and the covered-code list attached so the appeal starts with evidence.
Frequently asked questions — NCD 190.25
What does NCD 190.25 cover?
AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology, hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating patients with benign hepatocellular neoplasms or metastases from those with hepatocellular carcinoma and, as a non-specific tumor associated antigen, serves in marking germ cell neoplasms of the testis,… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 190.25 take effect?
The current version (1) is effective 11/25/2002, implemented 01/01/2003, published in transmittal 17. This is the only published version.
Does a Local Coverage Determination override NCD 190.25?
No. A National Coverage Determination binds all Medicare Administrative Contractors; an LCD can only address services or circumstances the NCD leaves open. Claims denied under this NCD typically return CARC 50 with remark N386 (NCD) rather than N115 (LCD).
Which diagnosis codes are covered under NCD 190.25?
The January 2026 laboratory NCD edit list contains 156 ICD-10-CM codes that support alpha-fetoprotein (for example A5274 Syphilis of liver and other viscera; B180 Chronic viral hepatitis B with delta-agent; B181 Chronic viral hepatitis B without delta-agent) and 245 codes that deny. The list applies to 82105.
How often does the lab NCD code list for 190.25 change?
CMS updates the laboratory NCD edit module quarterly, with the January release carrying the annual ICD-10-CM code changes. Codes added or deleted mid-year appear in the quarterly change spreadsheets on the Lab NCDs page.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database NCDs via the CMS Coverage APIVersion API snapshot 2026-09-27 · effective 2026-09-20 · file national-coverage-ncd.jsonSHA-256 a90fadfd264b9ef4…
- Laboratory NCD ICD-10 code lists, January 2026Version January 2026 · effective 2026-01-01 · file 2026100-Initial-ICD10-NCD-Spreadsheet-20250721-508.xlsxSHA-256 57ff5cd37ba523d3…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
This page reproduces the CMS National Coverage Determination text and, for laboratory NCDs, the CMS ICD-10 edit lists, as an operational reference. Coverage decisions depend on the full policy, the claim and the contractor; nothing here is legal, clinical or billing advice. CPT codes are shown as numbers only; CPT descriptors are copyright AMA.