0172U — Dna gene analysis (brca1, dna repair associated and brca2, dna repair associated) for detection of mutations associated with breast cancer
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
- To report a Molecular Diagnostic Test (MDT) service, submit the appropriate CPT code, include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field, and enter 1 unit of service (UOS).
- A molecular or genomic test may be covered when it provides new clinical diagnostic information that cannot be obtained from any other test or combination of tests and is reasonable and necessary for management of the Medicare beneficiary.
- A molecular panel is coverable when the medical record documents that the entire panel is reasonable and necessary for the beneficiary’s specific medical problem and will be used in patient management.
- Individual gene tests billed separately are coverable when the medical record documents that each individual gene test is reasonable and necessary for the beneficiary’s management.
- When using next generation sequencing (NGS), genes assayed in parallel for the same indication on the same date of service are considered a single panel and may be billed as such when reasonable and necessary.
- Advanced diagnostic laboratory tests (ADLTs) are allowable only when they provide new clinical diagnostic information that cannot be obtained from any other test or combination of tests (per 42 CFR 414.502).
17 Active Policies
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
L34519 — Molecular Pathology Procedures
J09
A58918 — Billing and Coding: Molecular Pathology and Genetic Testing
J09
L39367
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