Key facts for NCD 190.31
- 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
- 54 covered ICD-10
- 245 non-covered
TL;DR
NCD 190.31 sets Medicare's national policy for prostate specific antigen under the benefit category "Diagnostic Laboratory Tests", effective 11/25/2002 and implemented 01/01/2003. PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract signs and symptoms (e.g., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia and incontinence) as well as with patients with palpably… As a laboratory NCD it carries a national ICD-10 edit list: 54 diagnosis codes support medical necessity and 245 are denied, applied automatically by every Medicare contractor to 1 procedure code.
Item or service described
Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to six months after radical prostatectomy, PSA is reported to provide a sensitive indicator of persistent disease. Six months following introduction of antiandrogen therapy, PSA is reported as capable of distinguishing patients with favorable response from those in whom limited response is anticipated.
PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment.
Indications and limitations of coverage
Indications
PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract signs and symptoms (e.g., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia and incontinence) as well as with patients with palpably abnormal prostate glands on physician exam, and in patients with other laboratory or imaging studies that suggest the possibility of a malignant prostate disorder. PSA is also a marker used to follow the progress of prostate cancer once a diagnosis has been established, such as in detecting metastatic or persistent disease in patients who may require additional treatment. PSA testing may also be useful in the differential diagnosis of men presenting with as yet undiagnosed disseminated metastatic disease.
Limitations
Generally, for patients with lower urinary tract signs or symptoms, the test is performed only once per year unless there is a change in the patient's medical condition.
Testing with a diagnosis of 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 190.31 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 54 covered and 245 non-covered ICD-10-CM codes plus 1 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 |
|---|---|
| 84153 | CPT (descriptor licensed by AMA) |
The first 40 of 54 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 |
|---|---|---|
| C61 | Malignant neoplasm of prostate | 2015-10-01 |
| C675 | Malignant neoplasm of bladder neck | 2015-10-01 |
| C774 | Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes | 2015-10-01 |
| C775 | Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes | 2015-10-01 |
| C778 | Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions | 2015-10-01 |
| C7951 | Secondary malignant neoplasm of bone | 2015-10-01 |
| C7952 | Secondary malignant neoplasm of bone marrow | 2015-10-01 |
| C7982 | Secondary malignant neoplasm of genital organs | 2015-10-01 |
| D075 | Carcinoma in situ of prostate | 2015-10-01 |
| D400 | Neoplasm of uncertain behavior of prostate | 2015-10-01 |
| D495 | — | 2015-10-01 |
| D49511 | Neoplasm of unspecified behavior of right kidney | 2016-10-01 |
| D49512 | Neoplasm of unspecified behavior of left kidney | 2016-10-01 |
| D49519 | Neoplasm of unspecified behavior of unspecified kidney | 2016-10-01 |
| D4959 | Neoplasm of unspecified behavior of other genitourinary organ | 2016-10-01 |
| M3303 | Juvenile dermatomyositis without myopathy | 2017-10-01 |
| M3313 | Other dermatomyositis without myopathy | 2017-10-01 |
| M3393 | Dermatopolymyositis, unspecified without myopathy | 2017-10-01 |
| N139 | Obstructive and reflux uropathy, unspecified | 2015-10-01 |
| N320 | Bladder-neck obstruction | 2015-10-01 |
| N400 | Benign prostatic hyperplasia without lower urinary tract symptoms | 2015-10-01 |
| N401 | Benign prostatic hyperplasia with lower urinary tract symptoms | 2015-10-01 |
| N402 | Nodular prostate without lower urinary tract symptoms | 2015-10-01 |
| N403 | Nodular prostate with lower urinary tract symptoms | 2015-10-01 |
| N419 | Inflammatory disease of prostate, unspecified | 2015-10-01 |
| N429 | Disorder of prostate, unspecified | 2015-10-01 |
| R310 | Gross hematuria | 2015-10-01 |
| R311 | Benign essential microscopic hematuria | 2015-10-01 |
| R312 | — | 2015-10-01 |
| R3121 | Asymptomatic microscopic hematuria | 2016-10-01 |
| R3129 | Other microscopic hematuria | 2016-10-01 |
| R319 | Hematuria, unspecified | 2015-10-01 |
| R32 | Unspecified urinary incontinence | 2015-10-01 |
| R339 | Retention of urine, unspecified | 2015-10-01 |
| R350 | Frequency of micturition | 2015-10-01 |
| R351 | Nocturia | 2015-10-01 |
| R3911 | Hesitancy of micturition | 2015-10-01 |
| R3912 | Poor urinary stream | 2015-10-01 |
| R3914 | Feeling of incomplete bladder emptying | 2015-10-01 |
| R3915 | Urgency of urination | 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 190.31
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 190.31
What does NCD 190.31 cover?
PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract signs and symptoms (e.g., hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia and incontinence) as well as with patients with palpably abnormal prostate glands on physician exam, and in patients with other laboratory or imaging studies that suggest the possibility of a malignant prostate… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 190.31 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 190.31?
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 190.31?
The January 2026 laboratory NCD edit list contains 54 ICD-10-CM codes that support prostate specific antigen (for example C61 Malignant neoplasm of prostate; C675 Malignant neoplasm of bladder neck; C774 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes) and 245 codes that deny. The list applies to 84153.
How often does the lab NCD code list for 190.31 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.