Documentation requirements
To receive a SULT4A1 test denial, please submit the following claim information:
For a voluntary issued ABN, append with GX HCPCS modifier
To indicate a statutorily excluded service, append with a GY HCPCS modifier
For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
Enter the appropriate 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 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
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 |
|---|---|---|
| 81479 | HCPCS | Covered |