About this policy
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis L40199. Please submit the following claim information: • Select appropriate CPT ® or PLA code • Only 1 test may be billed per patient per 12 months • 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: o Loop 2400 or SV101-7 for the 5010A1 837P o 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: o Line SV202-7 for 837I electronic claim o Block 80 for the UB04 claim form • Select the appropriate ICD-10-CM codes o Must include at least one code from Group 1 and at least one code from Group 2 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. 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.
| Code | Code system | Status in this policy |
|---|---|---|
| 0003M | HCPCS | Covered |
| 0166U | HCPCS | Covered |
| 0344U | HCPCS | Covered |
| 0468U | HCPCS | Covered |
| 81479 | HCPCS | Covered |
| 81517 | HCPCS | Covered |
| 81599 | HCPCS | Covered |
| E11.00 | ICD10CM | Covered |
| E11.01 | ICD10CM | Covered |
| E11.10 | ICD10CM | Covered |
| E11.11 | ICD10CM | Covered |
| E11.21 | ICD10CM | Covered |
| E11.22 |