81283
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
- The article does not specify documentation requirements; follow the documentation, medical record, and prior authorization requirements described in LCD MolDX: Repeat Germline Testing L38429 and MolDX program guidance.
- 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.
Key Coverage Criteria
- Coverage for repeat germline testing is determined by the referenced Local Coverage Determination MolDX: Repeat Germline Testing L38429; consult that LCD for specific clinical indications that constitute covered testing.
- 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).
- Pharmacogenomic (PGx) testing is covered when ordered to guide selection or dosing of a drug or drugs being used or considered for the beneficiary where the gene–drug association is supported by CPIC or FDA guidance (see Tables 1–2).
- Testing of CYP2C9 and VKORC1 for warfarin dosing is covered only when performed in accordance with NCD 90.1 and its specified requirements.
- Pharmacogenomics (PGx) testing is covered when ordered to guide selection or dosing of specific drug(s) that the ordering physician is considering for the beneficiary and when the test is likely to identify the necessary alleles/variants to inform therapy.
- PGx testing is covered for the gene–drug pairs listed in the policy Tables 1 and 2 when the specific listed drug(s) are under consideration and the test result would inform clinical management (examples include CYP2C19 testing for clopidogrel and CYP2D6 testing for codeine/tramadol).
20 Active Policies
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A58395 — Billing and Coding: MolDX: Pharmacogenomics Testing
J05
A57100 — Billing and Coding: MolDX: Repeat Germline Testing
J05
L38435 — MolDX: Pharmacogenomics Testing
J05
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
Related Codes
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