Key facts for NCD 190.26
- 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
- 193 covered ICD-10
- 245 non-covered
TL;DR
NCD 190.26 sets Medicare's national policy for carcinoembryonic antigen under the benefit category "Diagnostic Laboratory Tests", effective 11/25/2002 and implemented 01/01/2003. CEA may be medically necessary for follow-up of patients with colorectal carcinoma. It would however only be medically necessary at treatment decision-making points. In some clinical situations (e.g. adenocarcinoma of the lung, small cell carcinoma of the… As a laboratory NCD it carries a national ICD-10 edit list: 193 diagnosis codes support medical necessity and 245 are denied, applied automatically by every Medicare contractor to 1 procedure code.
Item or service described
CEA is a protein 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
CEA may be medically necessary for follow-up of patients with colorectal carcinoma. It would however only be medically necessary at treatment decision-making points. In some clinical situations (e.g. adenocarcinoma of the lung, small cell carcinoma of the lung, and some gastrointestinal carcinomas) when a more specific marker is not expressed by the tumor, CEA may be a medically necessary alternative marker for monitoring. Preoperative CEA may also be helpful in determining the post-operative adequacy of surgical resection and subsequent medical management. In general, a single tumor marker will suffice in following patients with colorectal carcinoma or other malignancies that express such tumor markers.
In following patients who have had treatment for colorectal carcinoma, ASCO guideline suggests that if resection of liver metastasis would be indicated, it is recommended that post-operative CEA testing be performed every two to three months in patients with initial stage II or stage III disease for at least two years after diagnosis.
For patients with metastatic solid tumors which express CEA, CEA may be measured at the start of the treatment and with subsequent treatment cycles to assess the tumor's response to therapy.
Limitations
Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. However, it may be proper to order the test more frequently in certain situations, for example, when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence.
Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.
Note: Scroll down for links to the quarterly Covered Code Lists (including narrative).
Text reproduced from the CMS Medicare Coverage Database record for NCD 190.26 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 193 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 |
|---|---|
| 82378 | CPT (descriptor licensed by AMA) |
The first 40 of 193 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 |
|---|---|---|
| C153 | Malignant neoplasm of upper third of esophagus | 2015-10-01 |
| C154 | Malignant neoplasm of middle third of esophagus | 2015-10-01 |
| C155 | Malignant neoplasm of lower third of esophagus | 2015-10-01 |
| C158 | Malignant neoplasm of overlapping sites of esophagus | 2015-10-01 |
| C159 | Malignant neoplasm of esophagus, unspecified | 2015-10-01 |
| C160 | Malignant neoplasm of cardia | 2015-10-01 |
| C161 | Malignant neoplasm of fundus of stomach | 2015-10-01 |
| C162 | Malignant neoplasm of body of stomach | 2015-10-01 |
| C163 | Malignant neoplasm of pyloric antrum | 2015-10-01 |
| C164 | Malignant neoplasm of pylorus | 2015-10-01 |
| C165 | Malignant neoplasm of lesser curvature of stomach, unspecified | 2015-10-01 |
| C166 | Malignant neoplasm of greater curvature of stomach, unspecified | 2015-10-01 |
| C168 | Malignant neoplasm of overlapping sites of stomach | 2015-10-01 |
| C169 | Malignant neoplasm of stomach, unspecified | 2015-10-01 |
| C170 | Malignant neoplasm of duodenum | 2015-10-01 |
| C171 | Malignant neoplasm of jejunum | 2015-10-01 |
| C172 | Malignant neoplasm of ileum | 2015-10-01 |
| C173 | Meckel's diverticulum, malignant | 2015-10-01 |
| C178 | Malignant neoplasm of overlapping sites of small intestine | 2015-10-01 |
| C179 | Malignant neoplasm of small intestine, unspecified | 2015-10-01 |
| C180 | Malignant neoplasm of cecum | 2015-10-01 |
| C181 | Malignant neoplasm of appendix | 2015-10-01 |
| C182 | Malignant neoplasm of ascending colon | 2015-10-01 |
| C183 | Malignant neoplasm of hepatic flexure | 2015-10-01 |
| C184 | Malignant neoplasm of transverse colon | 2015-10-01 |
| C185 | Malignant neoplasm of splenic flexure | 2015-10-01 |
| C186 | Malignant neoplasm of descending colon | 2015-10-01 |
| C187 | Malignant neoplasm of sigmoid colon | 2015-10-01 |
| C188 | Malignant neoplasm of overlapping sites of colon | 2015-10-01 |
| C189 | Malignant neoplasm of colon, unspecified | 2015-10-01 |
| C19 | Malignant neoplasm of rectosigmoid junction | 2015-10-01 |
| C20 | Malignant neoplasm of rectum | 2015-10-01 |
| C210 | Malignant neoplasm of anus, unspecified | 2015-10-01 |
| C211 | Malignant neoplasm of anal canal | 2015-10-01 |
| C212 | Malignant neoplasm of cloacogenic zone | 2015-10-01 |
| C218 | Malignant neoplasm of overlapping sites of rectum, anus and anal canal | 2015-10-01 |
| C250 | Malignant neoplasm of head of pancreas | 2015-10-01 |
| C251 | Malignant neoplasm of body of pancreas | 2015-10-01 |
| C252 | Malignant neoplasm of tail of pancreas | 2015-10-01 |
| C253 | Malignant neoplasm of pancreatic duct | 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 190.26
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 190.26
What does NCD 190.26 cover?
CEA may be medically necessary for follow-up of patients with colorectal carcinoma. It would however only be medically necessary at treatment decision-making points. In some clinical situations (e.g. adenocarcinoma of the lung, small cell carcinoma of the lung, and some gastrointestinal carcinomas) when a more specific marker is not expressed by the tumor, CEA may be a medically necessary alternative marker for… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 190.26 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 190.26?
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 190.26?
The January 2026 laboratory NCD edit list contains 193 ICD-10-CM codes that support carcinoembryonic antigen (for example C153 Malignant neoplasm of upper third of esophagus; C154 Malignant neoplasm of middle third of esophagus; C155 Malignant neoplasm of lower third of esophagus) and 245 codes that deny. The list applies to 82378.
How often does the lab NCD code list for 190.26 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.