About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer L38966. To report a service, please submit the following claim information: Select appropriate CPT ® code Enter 1 unit of service (UOS) 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 Select the appropriate ICD-10-CM code Regarding single-gene and panel testing of genes-Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57503. Tier 1 and/or Tier 2 individual biomarker CPT ® codes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel. 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 .
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.
Showing the first 1,000 of 1,391 codes. The source has the full list.
| Code | Code system | Status in this policy |
|---|---|---|
| 0101U | HCPCS | Covered |
| 0102U | HCPCS | Covered |
| 0103U | HCPCS | Covered |
| 0129U | HCPCS | Covered |
| 0138U | HCPCS | Covered |
| 81163 | HCPCS | Covered |
| 81164 | HCPCS | Covered |
| 81165 | HCPCS | Covered |
| 81166 | HCPCS | Covered |
| 81167 | HCPCS | Covered |
| 81201 | HCPCS | Covered |
| 81202 | HCPCS | Covered |