C19, Malignant neoplasm of rectosigmoid junction
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Report BRAF V600 test kit services using CPT code 81210 on claims.
- Submit the assigned DEX Z-Code™ Identifier in the comment/narrative field: Loop 2400 or SV101-7 for 5010A1 837P electronic claims; alternatively use SV202-7 (preferred) or the NTE field.
- For paper Part B claims attach the DEX Z-Code identifier to the claim; for Part A enter the DEX Z-Code adjacent to CPT on Line SV202-7 for 837I electronic claims or Block 80 on the UB-04 form.
- Select and report the appropriate ICD-10-CM diagnosis code for melanoma on the claim.
- All labs submitting claims for a BRAF V600 test kit must register the test on the DEX Diagnostics Exchange (https://app.dexzcodes.com/login) and confirm unmodified use.
- Enter '1' in the Days/Unit field on the claim when billing the Oncotype DX Colon service.
Key Coverage Criteria
- BRAF V600 mutation testing (cobas® 4800 BRAF V600) is covered to detect BRAF mutation in melanoma to determine eligibility for vemurafenib (Zelboraf) in patients with melanoma that is unresectable or metastatic.
- BRAF V600E and V600K mutation testing (ThxID™ BRAF V600/K) is covered to identify melanoma patients whose tumors carry V600E and/or V600K mutations for selection of dabrafenib (Tafinlar) and/or trametinib (Mekinist).
- Oncotype DX Colon Cancer Assay is intended to predict recurrence risk for patients with Stage II colon cancer.
- Diagnostic colonoscopy or sigmoidoscopy is covered to directly visualize the lower gastrointestinal tract (colon, rectum, sigmoid) to detect polyps, tumors, or other intestinal lesions.
- Diagnostic colonoscopy is covered when identification of the site of pathology and/or obtaining a biopsy during the procedure is clinically indicated.
- A follow-on screening colonoscopy is covered after a positive covered blood-based biomarker noninvasive colorectal cancer (CRC) screening test per NCD 210.3, effective 2025-01-01.
20 Active Policies
CGS-L34037, Flow Cytometry
J15
CGS-L36658, Proton Beam Therapy
J15
CGS-L40225, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Predictive Testing in Cancer
J15
CGS-L34005, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
J15
CGS-L34356, Erythropoiesis Stimulating Agents (ESA)
J15
CGS-L36021, MolDX: Molecular Diagnostic Tests (MDT)
J15
CGS-L38822, MolDX: Minimal Residual Disease Testing for Cancer
J15
CGS-L38067, MolDX: Next-Generation Sequencing for Solid Tumors
J15
CGS-L39017, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
J15
CGS-L38065, MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J15
CGS-L35442, MolDX: NRAS Genetic Testing
J15
A58468, Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers
J5
A56394, Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic
J5
A57936, Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors
J5
A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer
J5
A55161, Billing and Coding: MolDX: FDA-Approved BRAF Tests
J5
A55231, Billing and Coding: MolDX: Oncotype DX Colon Cancer Assay Update
J5
A57581, Billing and Coding: MolDX: NRAS Genetic Testing
J5
A57858, Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors
J5
A56827, Billing and Coding: Proton Beam Therapy
J6
Related Codes
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