81268
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Enter the appropriate CPT code and report 1 unit of service (UOS) adjacent to the CPT code on the claim.
- Include the appropriate DEX Z-Code® identifier adjacent to the CPT code in the comment/narrative field using SV101-7 or Loop 2400 (837P) / Box 19 for paper claims for Part B and SV202-7 (837I) / Block 80 (UB04) for Part A; do not add extra characters on the SV101-7 field.
- Laboratories may use SV101-7, SV202-7 (preferred), or the NTE field to submit required information for claims.
- Requests for exceptions to the lifetime limit for CPT 81265 must be submitted through the appeal process for case-by-case approval.
Key Coverage Criteria
- Chimerism analysis to identify appropriate donors and to monitor engraftment success or disease recurrence is a covered Medicare service.
- Report CPT 81265 for recipient/donor testing (pre-transplant chimerism/donor identification) as a covered service.
- Report CPT 81266 as a covered service when used to report an additional double-cord blood sample in bone marrow transplants.
- Report CPT 81267 post-transplant to confirm successful engraftment or to detect disease recurrence by comparing pre- and post-transplant specimens.
- Report CPT 81268 to document chimerism testing using a buccal or other germline tissue specimen from the recipient post-transplantation.
- When a molecular panel of 5–50 genes is ordered, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) instead of submitting individual single-gene CPT codes.
20 Active Policies
A55621 — Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT codes 81265-81268)
J05
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A56199 — Billing and Coding: Molecular Pathology Procedures
J06
Related Codes
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