Documentation requirements
To report an FDA approved or laboratory developed test (LDT) EGFR test kit service, please submit the following claim information.
Loop 2400 or SV101-7 for the 5010A1 837P
Submit the assigned Z-Code™ Identifier on an attachment to the claim form for paper claim
Enter the appropriate 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
Select the correct ICD-10-CM diagnosis code(s).
NOTE : MolDX will apply NPI to ID editing on FDA approved EGFR kits. All labs that submit claims for an EGFR kit MUST register the test and confirm the UNMODIFIED use of the kit. Tests may be registered on the DEX Diagnostics Exchange ™: https://app.dexzcodes.com/login
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 81235 | HCPCS | Covered |
| C34.00 | ICD10CM | Covered |
| C34.01 | ICD10CM | Covered |
| C34.02 | ICD10CM | Covered |
| C34.11 | ICD10CM | Covered |
| C34.12 | ICD10CM | Covered |
| C34.2 | ICD10CM | Covered |
| C34.31 | ICD10CM | Covered |
| C34.32 | ICD10CM | Covered |
| C34.81 | ICD10CM | Covered |
| C34.82 | ICD10CM | Covered |
| C34.91 | ICD10CM | Covered |
| C34.92 | ICD10CM | Covered |