Billing and Coding: MolDX: BluePrint® Test

The MolDX team has completed a technical assessment on BluePrint ® , a molecular subtyping assay. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the BluePrint test is a statutorily excluded test. To receive a BluePrint ® service denial, please submit the following claim information: CPT code ® An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services For a voluntary issued ABN, append with GX modifier To indicate a statutorily excluded service, append with a GY modifier Enter DEX Z-Code ® identifier adjacent to the CPT ® code in the comment/narrative field for the following Part B claim field/types: Loop 2400 or SV101-7 for the 5010A1 837P Box 19 for paper claim. Enter DEX Z-Code ® identifier adjacent to the CPT ® code in the comment/narrative field for the following Part A claim field/types: Line SV202-7 for 837I electronic claim Block 80 for the UB04 claim form NOTE: When entering the DEX Z-Code on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line. Specific tests that have been evaluated for compliance with coverage criteria set in policy (and are thus covered or not covered) can be found in the DEX® registry located at www.dexzcodes.com