Z31.438 — Encounter for other genetic testing of female for procreative management
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
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.
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.
- When 5–50 genes are ordered as a molecular testing panel, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) rather than individual single-gene CPT codes.
- When 51 or more genes are ordered as a molecular testing panel for molecular biomarkers, bill the appropriate panel CPT code (81455 or 81456) rather than individual single-gene CPT codes.
5 Active Policies
A56199 — Billing and Coding: Molecular Pathology Procedures
J06
A59926 — Billing and Coding: Molecular Pathology Procedures
J06
L35000 — Molecular Pathology Procedures
J06
CIGNA-0514 — Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514)
Related Codes
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