0423U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For Part A UB04 paper claim forms, enter the DEX Z-Code adjacent to the CPT code in Block 80.
- For Part B electronic 5010A1 837P claims, enter the DEX Z-Code adjacent to the CPT code in Loop 2400 or SV101-7.
- For Part B paper claims, enter the DEX Z-Code adjacent to the CPT code in Box 19 of the paper claim form.
- For Part A electronic 837I claims, enter the DEX Z-Code adjacent to the CPT code on line SV202-7.
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).
- Pharmacogenomics (PGx) testing is covered when it is reasonable and necessary per LCD L39063 and Medicare coverage rules for the beneficiary's clinical indication.
- CPT 81418 (PGx multi-gene panel) is covered when the test assays at least 6 genes, including CYP2C19 and CYP2D6 and CYP2D6 duplication/deletion analysis, and the panel is clinically indicated to guide drug therapy.
- A clinician-ordered single gene or allele test is considered covered when the billed component corresponds to the single gene/allele that was reasonable and necessary, even if the laboratory platform concurrently interrogated other genes operationally.
- Germline testing panels that include some previously tested genetic content may be covered if there is established clinical utility for the remaining non-duplicative genetic components of the panel.
- Genes may be assayed serially or in parallel; additional gene analyses done after a reflex decision are covered when those reflexive analyses are reasonable and necessary for the beneficiary's care.
20 Active Policies
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A58812 — Billing and Coding: Pharmacogenomics Testing
J09
L34519 — Molecular Pathology Procedures
J09
L39367 — Genetic Testing in Oncology: Specific Tests
Related Codes
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