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National Coverage Determination (NCD)

Carcinoembryonic Antigen

190.26

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Tracking Information

Publication Number
100-3
Manual Section Number
190.26
Manual Section Title
Carcinoembryonic Antigen
Version Number
1
Effective Date of this Version
11/25/2002
Ending Effective Date of this Version
Implementation Date
01/01/2003
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Laboratory Tests


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

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).
Cross Reference

Also see the Medicare Claims Processing Manual Opens in a new window, Chapter 120, Clinical Laboratory Services Based on Negotiated Rulemaking.
Claims Processing Instructions

Transmittal Information

Transmittal Number
17
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R17NCD.pdf Opens in a new window
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 Opens in a new window) (CR 2130)

07/2002 - Implemented NCD. Effective date 11/25/02.  Implementation date 1/01/03. (TN AB-02-110 Opens in a new window) (CR 2130)
Other

Covered Code Lists (including narrative)

January 2025 (PDF) (ICD-10 Opens in a new window)
October 2024 (PDF) (ICD-10 Opens in a new window)
July 2024 (PDF) (ICD-10 Opens in a new window)
April 2024 (PDF) (ICD-10 Opens in a new window)
January 2024 (PDF) (ICD-10 Opens in a new window)
October 2023 (PDF) (ICD-10 Opens in a new window)
July 2023 (PDF) (ICD-10 Opens in a new window)
April 2023 (PDF) (ICD-10 Opens in a new window)
January 2023 (PDF) (ICD-10 Opens in a new window)
October 2022 (PDF) (ICD-10 Opens in a new window)
July 2022 (PDF) (ICD-10 Opens in a new window)
April 2022 (PDF) (ICD-10 Opens in a new window)
January 2022 (PDF) (ICD-10 Opens in a new window)
October 2021 (PDF) (ICD-10 Opens in a new window)
July 2021 (PDF) (ICD-10 Opens in a new window)
April 2021 (PDF) (ICD-10 Opens in a new window)
January 2021 (PDF) (ICD-10 Opens in a new window)
October 2020 (PDF) (ICD-10 Opens in a new window)
July 2020 (PDF) (ICD-10 Opens in a new window)
April 2020 (PDF) (ICD-10 Opens in a new window)
January 2020 (PDF) (ICD-10 Opens in a new window)
October 2019 (PDF) (ICD-10 Opens in a new window)
July 2019 (PDF) (ICD-10 Opens in a new window)
April 2019 (PDF) (ICD-10 Opens in a new window)
January 2019 (PDF) (ICD-10 Opens in a new window)
October 2018 (PDF) (ICD-10 Opens in a new window)
July 2018 (PDF) (ICD-10 Opens in a new window)
April 2018 (PDF) (ICD-10 Opens in a new window)
January 2018 (ICD-10 Opens in a new window)
October 2017 (ICD-10 Opens in a new window)
July 2017 (ICD-10 Opens in a new window)
April 2017 (ICD-10 Opens in a new window)
January 2017 (ICD-10 Opens in a new window)
October 2016 (ICD-10 Opens in a new window)
January 2016 (ICD-10 Opens in a new window)
October 2015 (ICD-10 Opens in a new window, ICD-9 Opens in a new window)
October 2014 (ICD-10 Opens in a new window, ICD-9 Opens in a new window)

Changes to Lab NCD Edit Software

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National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between View the document version
Carcinoembryonic Antigen 1 11/25/2002 - N/A You are here
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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