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
02101 - A and B MAC
Alaska
02102 - A and B MAC
Alaska
02201 - A and B MAC
Idaho
02202 - A and B MAC
Idaho
02301 - A and B MAC
Oregon
02302 - A and B MAC
Oregon
02401 - A and B MAC
Washington
02402 - A and B MAC
Washington
03101 - A and B MAC
Arizona
03102 - A and B MAC
Arizona
03201 - A and B MAC
Montana
03202 - A and B MAC
Montana
03301 - A and B MAC
North Dakota
03302 - A and B MAC
North Dakota
03401 - A and B MAC
South Dakota
03402 - A and B MAC
South Dakota
03501 - A and B MAC
Utah
03502 - A and B MAC
Utah
03601 - A and B MAC
Wyoming
03602 - A and B MAC
Wyoming
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:
01/22/2026
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 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
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
01/22/2026
R6
Revision Effective Date: 01/22/2026
CONTRACTOR INFORMATION:
Added: JF contractor information
This update is to consolidate JE and JF to have one unified document and policy number.
11/07/2024
R5
Under Article Text: Formatting, punctuation, and typographical errors were corrected.
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.
