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: A57423 Status: A-Approved
Article Title: Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)
Original Article Effective Date:
11/01/2019
Revision Effective Date:
11/07/2024
Article Text:
The following coding and billing guidance is to be used with its associated Local coverage determination.
To report a Genetic Testing for Hypercoagulability/Thrombophilia 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 SV010-7 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
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.
MOLECULAR PATHOLOGY PROCEDURE, LEVEL 1 (EG, IDENTIFICATION OF SINGLE GERMLINE VARIANT [EG, SNP] BY TECHNIQUES SUCH AS RESTRICTION ENZYME DIGESTION OR MELT CURVE ANALYSIS)
ICD-10 Codes That Are Covered
XX000
Not Applicable
ICD-10 Codes That Are Not Covered
N/A
Revision History Information
Revision History Date
Revision History Number
Revision History Explanation
11/07/2024
R4
Under CMS National Coverage Policy revised the following regulation: CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5 Jurisdiction of Laboratory Claims, §60.1.1 Independent Laboratory Specimen Drawing, §60.2 Travel Allowance. 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”. Under CPT/HCPCS Codes Group 1: Codes added: 81400.
08/12/2021
R3
Updated to indicate this article is an LCD Reference Article.
08/12/2021
R2
Formatting, punctuation, and typographical errors were corrected throughout the Article.
