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. 999 Not 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 E34.00 Carcinoid syndrome, unspecified E34.01 Carcinoid heart syndrome E34.09 Other 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 Date Revision History Number Revision History Explanation 10/01/2024 R8 Revision Effective Date: 10/1/2024 ICD-10-CM CODES THAT SUPPORT MEDICAL NECESITY:  Added: ICD-10-CM code E34.00, E34.01 and E34.09 to Group 1 Codes Deleted: ICD-10-CM code E34.0 to Group 1 Codes 10/1/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination. This revision is due to the 2024 Annual ICD-10 updates.  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