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: A57421 Status: A-Approved
Article Title: Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease
Original Article Effective Date:
11/01/2019
Revision Effective Date:
01/01/2024
Article Text:
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36180. For single genes performed by NGS, these tests must demonstrate compliance with L38123 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies and its accompanying billing and coding article, A55624 Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer.
To report Genetic Testing for BCR-ABL Negative Myeloproliferative Disease service, please submit the following claim information:
Select appropriate CPT® code
Enter 1 unit of service (UOS)
Enter the appropriate DEX Z-Code® identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types:
Loop 2400 or SV101-7 for the 5010A1 837P
Item 19 for paper claim
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:
Line SV202-7 for 837I electronic claim
Block 80 for the UB04 claim form
Select the appropriate ICD-10-CM code
NOTE: When entering the DEX Z- Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
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.
HEMATOLYMPHOID NEOPLASM OR DISORDER, GENOMIC SEQUENCE ANALYSIS PANEL, 5-50 GENES, INTERROGATION FOR SEQUENCE VARIANTS, AND COPY NUMBER VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION LEVELS, IF PERFORMED; DNA ANALYSIS OR COMBINED DNA AND RNA ANALYSIS
81479
UNLISTED MOLECULAR PATHOLOGY PROCEDURE
ICD-10 Codes That Are Covered
N/A
C88.8
Other malignant immunoproliferative diseases
C91.00
Acute lymphoblastic leukemia not having achieved remission
C91.01
Acute lymphoblastic leukemia, in remission
C91.02
Acute lymphoblastic leukemia, in relapse
C92.10
Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.11
Chronic myeloid leukemia, BCR/ABL-positive, in remission
C92.12
Chronic myeloid leukemia, BCR/ABL-positive, in relapse
C92.20
Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission
C92.21
Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission
C92.22
Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse
C93.10
Chronic myelomonocytic leukemia not having achieved remission
C94.40
Acute panmyelosis with myelofibrosis not having achieved remission
C94.41
Acute panmyelosis with myelofibrosis, in remission
C94.42
Acute panmyelosis with myelofibrosis, in relapse
C94.6
Myelodysplastic disease, not elsewhere classified
D45
Polycythemia vera
D46.0
Refractory anemia without ring sideroblasts, so stated
D46.1
Refractory anemia with ring sideroblasts
D46.21
Refractory anemia with excess of blasts 1
D46.22
Refractory anemia with excess of blasts 2
D46.A
Refractory cytopenia with multilineage dysplasia
D46.B
Refractory cytopenia with multilineage dysplasia and ring sideroblasts
D46.C
Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.Z
Other myelodysplastic syndromes
D47.02
Systemic mastocytosis
D47.1
Chronic myeloproliferative disease
D47.3
Essential (hemorrhagic) thrombocythemia
D47.4
Osteomyelofibrosis
D47.Z9
Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D72.821
Monocytosis (symptomatic)
D75.1
Secondary polycythemia
D75.81
Myelofibrosis
D75.838
Other thrombocytosis
D75.89
Other specified diseases of blood and blood-forming organs
ICD-10 Codes That Are Not Covered
N/A
Revision History Information
Revision History Date
Revision History Number
Revision History Explanation
01/01/2024
R10
Under CPT/HCPCS Codes Group 1: Codes the description was revised for 81450. This revision is due to the 2024 Annual/Q1 CPT/HCPCS Code Update and is effective 1/1/2024.
Under CMS National Coverage Policy updated section heading for 2nd regulation. Under Article Text revised 3rd and 6th bullets to remove “DEX Z-Code™” and replaced with “DEX Z-Code®”. Added “NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line”. This revision is effective 1/1/2024.
01/01/2023
R9
Updated to indicate this article is an LCD Reference Article.
01/01/2023
R8
Under CPT/HCPCS Codes Group 1: Codes the description was revised for 81450. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2023.
10/01/2022
R7
Under ICD-10 Codes that Support Medical Necessity Group 1: Codes the description was revised for C94.6. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/2022.
03/17/2022
R6
Under Article Text added verbiage, "For single genes performed by NGS, these tests must demonstrate compliance with L38123 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies and its accompanying billing and coding article, A55624 Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer.” This revision is effective on 03/17/2022.
10/01/2021
R5
Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes added D75.838. This revision is due to the Annual ICD-10 Update and will become effective on 10/1/21.
07/01/2021
R4
Under CPT/HCPCS Codes Group 1: Code added 0040U. This revision is due to the code being previously omitted in error and is retroactive effective for date of service on or after 01/13/2020.
07/01/2021
R3
Under CMS National Coverage Policy moved CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests to the related LCD.
Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted D46.20, D46.4, D46.9, D47.9, D72.829, and D75.9.
01/01/2021
R2
Under CPT/HCPCS Codes Group 1: Codes added 0027U and deleted 81402. Deleted CPT/HCPCS Codes Group 2 Paragraph and CPT/HCPCS Codes Group 2: Codes including 81403, 81445, 81455. Due to the deletion of CPT/HCPCS Codes Group 2: Codes 81450 was moved to CPT/HCPCS Codes Group 1: Codes.
Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph deleted the verbiage, “Group 1 CPT codes and Group 2 CPT codes apply to Group 1 ICD-10 Codes”. This revision is retroactive effective for dates of service on or after 1/1/2021.
Under CPT/HCPCS Codes Group 1: Codes added 81279, 81338 and 81339. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021
11/07/2019
R1
Article is revised to add CMS references. Under CPT/HCPCS Codes Group 1: Codes deleted CPT® codes 81403, 81445, 81450, and 81455. Under CPT/HCPCS Codes Group 2: Paragraph added verbiage, “CPT® codes that are also referenced in other articles”. Under CPT/HCPCS Group 2: Codes added CPT® codes 81403, 81445, 81450, and 81455.
