Local Coverage Article Billing and Coding

Billing and Coding: MolDX: CHD7 Gene Analysis Guidelines

A54243

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Contractor Information

Article Information

General Information

Article ID
A54243
Article Title
Billing and Coding: MolDX: CHD7 Gene Analysis Guidelines
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
10/17/2019
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Sec. 1862 (1)(A) Statutory Exclusion covers diagnostic testing “except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,…”

Article Guidance

Article Text

Effective for dates of service on and after June 26, 2013

CHD7 gene testing may be performed during the diagnosis of CHARGE Syndrome. Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, CGS Administrators and the MolDX Program contractor has determined CHD7 gene testing is a statutorily excluded service. CGS and the MolDX Program contractor will also deny tests that include one or more of CHD7 tests reported with CPT code 81479 as statutorily excluded services.

To receive a CHD7 analysis service denial, please submit the following claim information:

  • Select appropriate CPT code
    • 81407 CHD7, full gene sequencing
    •  81479 all other CHD7 testing 
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services. 
  • For a voluntary issued ABN, append with GX modifier
  • To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier 
  • Select the appropriate diagnosis for the patient
  •  Enter the appropriate identifier adjacent to the CPT code in the comment/narrative field for the following claim field/types: 
    • Loop 2300 NTE01 for Part A or Loop 2400 NTE02 for Part B
    • Form locator 80 for Part A or Box 19 for Part B on paper claim



Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
81407 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 8 (EG, ANALYSIS OF 26-50 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF >50 EXONS, SEQUENCE ANALYSIS OF MULTIPLE GENES ON ONE PLATFORM) APOB (APOLIPOPROTEIN B) (EG, FAMILIAL HYPERCHOLESTEROLEMIA TYPE B) FULL GENE SEQUENCE
81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE

CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT

ICD-10-CM Codes that Support Medical Necessity

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/17/2019 R9

Revision Effective date: 10/17/2019
Revision Explanation: Added the reference sentence from article text to CMS National Policy section, corrected formatting , added modifiers and CPT codes to applicable sections.

10/03/2019 R8

Revision Effective date: n/a
Revision Explanation: Converted article into new billing and coding article format.

10/03/2019 R7

Revision Effective date: 10/03/2019
Revision Explanation: Converted article into new billing and coding article format.

10/01/2015 R6

Revision Effective date: N/A
Revision Explanation: Annual review no changes made.

10/01/2015 R5

Revision Effective date: N/A
Revision Explanation: Annual review no changes made

10/01/2015 R4 Revision Effective date: N/A
Revision Explanation: Annual review no changes made.
10/01/2015 R3 Revision Effective: N/A
Revision Explanation: Annual review no changes made.
10/01/2015 R2 R1
Revision Effective:10/01/2015
Revision Explanation: Changed MoPath to MolDX.
10/01/2015 R1 Revision Effective: N/A
Revision Explanation: Added Part A loop information.

Associated Documents

Related Local Coverage Documents
LCDs
L36021 - MolDX: Molecular Diagnostic Tests (MDT)
Related National Coverage Documents
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Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
12/20/2019 10/17/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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