About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prometheus ® IBD sgi Diagnostic ® Policy L37539. To receive a Prometheus ® IBD sgi Diagnostic ® denial, please submit the following claim information: Select the applicable CPT ® code Enter 1 unit of service (UOS) 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 If submitting a DEX Z-Code™ identifier, 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 If submitting a DEX Z-Code™ identifier, 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 |