D75.9 — Disease of blood and blood-forming organs, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must report the appropriate CPT code for the flow cytometry service, include 1 unit of service (UOS), and list the appropriate ICD-10-CM diagnosis code.
- Medical necessity documentation per LCD L34513 is required when coverage criteria are not fully met in this billing guideline (for example, when >24 markers are requested).
- 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.
Key Coverage Criteria
- Coverage and medical necessity determinations for flow cytometry are governed by Local Coverage Determination L34513.
- Flow cytometry may be used to analyze cellular components of body fluids and lymphoreticular tissues, including peripheral blood, cerebrospinal fluid (CSF), bone marrow, lymph nodes, tonsil, spleen, and fine needle aspirate material.
- Peripheral blood or fine needle aspirate specimens may be used to avoid more invasive diagnostic procedures when clinically appropriate.
- 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.
13 Active Policies
A59926 — Billing and Coding: Molecular Pathology Procedures
J06
A56793 — Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
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A56199 — Billing and Coding: Molecular Pathology Procedures
J06
L35000 — Molecular Pathology Procedures
J06
Related Codes
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