81375
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Documentation Required
- The medical record must document that the testing is expected to influence treatment of the condition for which the test is ordered and include an ordering physician/NPP requisition containing the relevant ICD-10-CM diagnosis code.
- Ordering physician/NPP documentation should include history and physical or exam findings, problems/diagnoses, and relevant data (e.g., lab tests, imaging) that support medical necessity.
- Performing laboratories must retain accreditation, test requisition, test records/procedures, preliminary and final reports, and quality control records and provide them when requested.
- For laboratory-developed tests (LDTs)/protocols, documentation must include the diagnostic test/assay, lab/manufacturer, comparable assays (if relevant), assay description, analytical validity, clinical validity, and clinical utility.
- When CPT 81479 (unlisted molecular pathology procedure) is used, documentation must clearly identify the unique molecular pathology procedure performed and link that procedure to the billed code.
- When multiple procedure codes (unique and/or unlisted) are submitted on a claim, the documentation supporting each code must be easily identifiable and linkable to the billed codes.
Key Coverage Criteria
- 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.
- When 51 or more genes are ordered for molecular biomarkers, bill the appropriate large-panel CPT code (81455 or 81456) rather than individual gene codes.
- When a panel contains more than one but fewer than five genes, use the corresponding existing panel CPT code or CPT 81479 (unlisted molecular pathology procedure) if no specific panel CPT exists.
- Use modifier 91 only when a test is performed more than once on the same day for the same patient and the repeat testing is necessary to obtain multiple results in the course of treatment.
- Coverage determinations for biomarker testing follow Local Coverage Determination L35062 and services are covered when reasonable and necessary per that LCD.
- HLA testing for histocompatibility is covered when performed as part of solid organ acquisition services for Medicare-covered transplants (kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, intestinal/multi-visceral) by an approved transplant center.
20 Active Policies
A57851 — Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility
J05
A59926 — Billing and Coding: Molecular Pathology Procedures
J06
A56199 — Billing and Coding: Molecular Pathology Procedures
J06
L35000 — Molecular Pathology Procedures
J06
L34519 — Molecular Pathology Procedures
J09
L39367 — Genetic Testing in Oncology: Specific Tests
J09
A58918 — Billing and Coding: Molecular Pathology and Genetic Testing
J09
L39063 — Pharmacogenomics Testing
J12
A56541 — Billing and Coding: Biomarkers Overview
J12
A58917 — Billing and Coding: Molecular Pathology and Genetic Testing
J12
L35062 — Biomarkers Overview
J12
L39365 — Genetic Testing in Oncology: Specific Tests
J12
FIRST_COAST-L34519 — Molecular Pathology Procedures
J9 MAC Part B
FIRST_COAST-L39367 — Genetic Testing in Oncology: Specific Tests
J9 MAC Part B
NGS-L35000 — Molecular Pathology Procedures
JK MAC Part B
NOVITAS-L35062 — Biomarkers Overview
JL MAC Part B
NOVITAS-L39063 — Pharmacogenomics Testing
JL MAC Part B
NOVITAS-L39365 — Genetic Testing in Oncology: Specific Tests
JL MAC Part B
A57970 — Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility
BCBSNM-SUR703.029 — Hematopoietic Cell Transplantation for Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)
Related Codes
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