Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (A57423)


Related Local Coverage Determination (LCD)
L36155-MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR)


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: 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: 08/12/2021

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

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.

0TBD

CPT/HCPCS Codes:

Group 1 Paragraph: N/A

Group 1 CPT Codes:
81240 F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT
81241 F5 (COAGULATION FACTOR V) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, LEIDEN VARIANT
81291 MTHFR (5,10-METHYLENETETRAHYDROFOLATE REDUCTASE) (EG, HEREDITARY HYPERCOAGULABILITY) GENE ANALYSIS, COMMON VARIANTS (EG, 677T, 1298C)


ICD-10 Codes That Are Covered

XX000 Not Applicable

ICD-10 Codes That Are Not Covered

N/A


Revision History Information
Revision History DateRevision History NumberRevision History Explanation
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.

11/01/2019
R1

CMS references are revised.