C78.5 — Secondary malignant neoplasm of large intestine and rectum
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Use CPT code 81540 on the claim when billing for Cancer TYPE ID.
- Enter '1' in the Days/Unit field on the claim for this test.
- Submit the required test identifier information using SV101-7 or SV202-7 (SV202-7 preferred) or via the NTE field if needed.
- Include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field for Part B claims (Loop 2400 or SV101-7 for 5010A1 837P; Box 19 for paper claims).
Key Coverage Criteria
- Bill Cancer TYPE ID using CPT code 81540 (mRNA gene expression assay of 92 genes) for evaluation of tumors of unknown origin.
- therascreen® KRAS test: detection of somatic KRAS mutations to identify colorectal cancer (CRC) patients for treatment with cetuximab (Erbitux®).
- cobas® KRAS test: detection of KRAS mutations in codons 12 and 13 to identify colorectal cancer (CRC) patients for treatment with cetuximab (Erbitux®) or panitumumab (Vectibix®).
- Diagnostic colonoscopy is covered when the service meets the reasonable and necessary requirements specified in Local Coverage Determination L33671.
- 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.
20 Active Policies
L34614 — Colonoscopy and Sigmoidoscopy-Diagnostic
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A57581 — Billing and Coding: MolDX: NRAS Genetic Testing
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A55147 — Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID Update
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L38678 — MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells
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A58205
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