0111U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Enter 1 unit of service (UOS) for the Molecular Diagnostic Test on the claim.
- Report the appropriate CPT code for the Molecular Diagnostic Test on the claim.
- For Part B electronic (837P) claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in Loop 2400 or the SV101-7 comment/narrative field.
- For Part B paper claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in Box 19.
Key Coverage Criteria
- Report molecular pathology CPT codes for nucleic acid analyses to detect germline or somatic gene variants or to test for histocompatibility antigens (e.g., HLA).
- Use HCPCS G0452 with modifier 26 when a pathologist performs the interpretation of a molecular pathology test.
- Assign an unlisted molecular pathology CPT code 81479 if the analyte tested is not listed under Tier 2 codes and is not represented by a Tier 1 CPT code.
- Report a CPT code described as “full gene sequence” only when the performed assay is a full gene sequence.
- Code selection should be based on the specific gene(s) analyzed and include all variants tested within the labelled CPT code (additional variants tested are included and not reported separately unless otherwise specified).
- Pathologists should bill interpretation services using G0452 with modifier 26; non-physician practitioners are not eligible to bill G0452.
18 Active Policies
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
L34519 — Molecular Pathology Procedures
J09
L39367 — Genetic Testing in Oncology: Specific Tests
J09
A58918 — Billing and Coding: Molecular Pathology and Genetic Testing
Related Codes
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