Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55028)


Related Local Coverage Determination (LCD)
L36678-Lab: Bladder/Urothelial Tumor Markers


Contractor NameContract NumberStates
Noridian Healthcare Solutions, LLC 01111 - A and B MAC California - Entire State
01112 - A and B MAC California - Northern
01182 - A and B MAC California - Southern
01211 - A and B MAC American Samoa
Guam
Hawaii
Northern Mariana Islands
01212 - A and B MAC American Samoa
Guam
Hawaii
Northern Mariana Islands
01311 - A and B MAC Nevada
01312 - A and B MAC Nevada
01911 - A and B MAC American Samoa
California - Entire State
Guam
Hawaii
Nevada
Northern Mariana Islands

Article Information

Article ID Number: A55028 Status: A-Approved

Article Title: Billing and Coding: Lab: Bladder/Urothelial Tumor Markers

Original Article Effective Date: 05/16/2017

Revision Effective Date: 09/22/2022

Article Text:

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36678).

Noridian will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion™ Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion™ Bladder Kit services may only be billed by a CLIA certified lab.

To bill UroVysion™ Bladder Kit services, submit the following claim information:

  • Select CPT® code 88120 or 88121 as appropriate.

Laboratories reporting only the technical component for a UroVysion™ service should append the appropriate code 88120 or 88121 with the TC modifier.

  • Select CPT® code 88120 or 88121 as appropriate.

Note: Physicians may NOT submit claims for a code 88120 and 88121 professional components when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.

To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:

  • Select the appropriate CPT® code.
  • Enter 1 unit of service (UOS)
  • Select the appropriate ICD-10 code.

 

Coding Information
Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999Not Applicable

CPT/HCPCS Codes:

Group 1 Paragraph:

N/A



Group 1 CPT Codes:
86294 IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR SEMIQUANTITATIVE (EG, BLADDER TUMOR ANTIGEN)
86316 IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH
86386 NUCLEAR MATRIX PROTEIN 22 (NMP22), QUALITATIVE
88120 CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR PROBES, EACH SPECIMEN; MANUAL
88121 CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR PROBES, EACH SPECIMEN; USING COMPUTER-ASSISTED TECHNOLOGY


ICD-10 Codes That Are Covered

N/A

C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.7 Malignant neoplasm of urachus
C67.8 Malignant neoplasm of overlapping sites of bladder
C67.9 Malignant neoplasm of bladder, unspecified
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.098 Malignant carcinoid tumors of other sites
C7A.8 Other malignant neuroendocrine tumors
C7B.01 Secondary carcinoid tumors of distant lymph nodes
C7B.02 Secondary carcinoid tumors of liver
C7B.03 Secondary carcinoid tumors of bone
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
C7B.8 Other secondary neuroendocrine tumors
D09.0 Carcinoma in situ of bladder
D41.4 Neoplasm of uncertain behavior of bladder
D49.4 Neoplasm of unspecified behavior of bladder
E34.0 Carcinoid syndrome
R31.0 Gross hematuria
R31.1 Benign essential microscopic hematuria
R31.21 Asymptomatic microscopic hematuria
R31.29 Other microscopic hematuria
Z78.9 Other specified health status
Z85.51 Personal history of malignant neoplasm of bladder
ICD-10 Codes That Are Not Covered

N/A


Revision History Information
Revision History DateRevision History NumberRevision History Explanation
09/22/2022
R7

Updated to indicate this article is an LCD Reference Article.

09/22/2022
R6

Under Article Text removed verbiage regarding instructions on how to submit a DEX Z-code™ on claims and how to register a test for a DEX Z-code™ identifier.

02/11/2021
R5

Under Article Text inserted UroVysion™ where applicable. In paragraphs 3 and 5 revised 1st bullet points to read "Select CPT® code 88120 or 88121 as appropriate," and 2nd and 3rd bullet points to read "Enter the appropriate DEX Z-CODE™ Identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:". Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted C7A.00, C7A.019, C7A.029, C7A.094, C7A.095, C7A.096, C7B.00, C78.00 and R31.9.  Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the article.

10/01/2019
R4

10/01/2019: This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Lab: Bladder/Urothelial Tumor Markers L36678 LCD and placed in this article.

Moved all verbiage in the ICD-10 Codes that Support Medical Necessity Group 1: Paragraph section to the Group 1: Medical Necessity ICD-10 Codes Asterisk Explanation section. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes placed an asterisk by ICD-10 Codes R31.21, R31.29 and Z78.9. Under CPT/HCPCS Modifiers added modifier TC. CPT® was inserted throughout the article where applicable.

10/01/2019
R3

Converted to Billing and Coding article.

Changed name from "MolDX: Bladder Tumor Marker FISH Billing and Coding Guidelines" to "Billing and Coding: Lab: Bladder/Urothelial Tumor Markers" to match LCD.

10/01/2017
R2

R2-Added MolDX in title, added coding instructions for all other services that meet the code 88120 or 88121by any provider type and specified "identifier" as DEX Z-Code™ identifier in the test registration paragraph.

 

05/16/2017
R1

Added billing information for Part A and clarified it for Part B