About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer L38997. To report a Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer service, please submit the following claim information: Select the 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 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. Additional information: Only one molecular biomarker test may be performed per date of service. Only one molecular biomarker test may be performed for a given clinical indication, as allowed by the policy.
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.