LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: BCKDHB Gene Test

A54255

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54255
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: BCKDHB Gene Test
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
11/16/2023
Revision Ending Date
N/A
Retirement Date
N/A
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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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CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A), states that no Medicare payment shall be made for items or 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 February 7, 2013

BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) gene testing identifies mutations in the BCKDHA, BCKDHB, DBT, and DLD genes causing maple syrup urine disease (MSUD). Genetic testing identifies parents at risk for conceiving a child with MSUD. Therefore, CGS Administrators and the MolDX Program contractor has determined that BCKDHB gene testing to identify parents at risk is not a Medicare benefit and a statutorily excluded test. In addition to single disease testing, CGS and the MolDX program contractor will also deny panels of tests that include the BCKDHB gene as a statutorily excluded test

To receive a BCKDHB test service denial, please submit the following claim information:

  • 81205-BCKDHB, common variants
  • 81406-BCKDHM, full gene sequence
  • 81443-Genetic testing for severe inherited conditions
  • 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
  • Select the appropriate diagnosis for the patient
  • Enter the DEX Z-Code™ identifier adjacent to each CPT® code in the stack in the comment/narrative field for the following claim field/types:
    • Loop SV202-7for Part A or Loop 2400 NTE02/SV101-7 for Part B
    • Form locator 80 for Part A or Box 19 for Part B on paper claim



Response To Comments

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1
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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

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Group 1 Codes
Code Description
81205 BCKDHB (BRANCHED-CHAIN KETO ACID DEHYDROGENASE E1, BETA POLYPEPTIDE) (EG, MAPLE SYRUP URINE DISEASE) GENE ANALYSIS, COMMON VARIANTS (EG, R183P, G278S, E422X)

Group 2

(2 Codes)
Group 2 Paragraph

CPT® codes that are also referenced in other articles.

 

Group 2 Codes
Code Description
81406 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 7 (EG, ANALYSIS OF 11-25 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 26-50 EXONS, CYTOGENOMIC ARRAY ANALYSIS FOR NEOPLASIA)
81443 GENETIC TESTING FOR SEVERE INHERITED CONDITIONS (EG, CYSTIC FIBROSIS, ASHKENAZI JEWISH-ASSOCIATED DISORDERS [EG, BLOOM SYNDROME, CANAVAN DISEASE, FANCONI ANEMIA TYPE C, MUCOLIPIDOSIS TYPE VI, GAUCHER DISEASE, TAY-SACHS DISEASE], BETA HEMOGLOBINOPATHIES, PHENYLKETONURIA, GALACTOSEMIA), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 15 GENES (EG, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)
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CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
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
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ICD-10-CM Codes that Support Medical Necessity

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

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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.

Code Description
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.

Code Description
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Other Coding Information

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
11/16/2023 R13

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

10/24/2019 R12

Revision Effective date: 10/24/2019
Revision Explanation: Removed guidelines from article title. Under
Article Text deleted the sentence “Select the appropriate diagnosis for the patient”. Under CPT/HCPCS Codes Group 1: Codes deleted CPT® codes 81406 and 81443. Under CPT/HCPCS Codes Group 2: Paragraph added verbiage “CPT® codes that are also referenced in other articles.” Under CPT/HCPCS Codes Group 2: Codes added CPT® codes 81406 and 81443. Under CPT/HCPCS Modifiers added modifiers GX and GY.

10/03/2019 R11

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

10/03/2019 R10

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

01/01/2019 R9

Revision Effective date: 01/01/2019
Revision Explanation: During annual HCPCS review new code 81443 was added to the article as well as 81406.

10/01/2015 R8

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

10/01/2015 R7

Revision Effective date: N/A
Revision Explanation: Added DEX Z-code™ for correct name of the identifier and updated electronic claim  information for Part A.

 

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: N/A
Revision Explanation: Annual review no changes made.
10/01/2015 R3 R1
Revision Effective:10/01/2015
Revision Explanation: Changed MoPath to MolDX.
10/01/2015 R2 Revision Effective: N/A
Revision Explanation: Added Part A loop information.
10/01/2015 R1 Revision #:R1
Revision Effective: 10/01/2015
Revision Explanation: Corrected typo in title.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L36021 - MolDX: Molecular Diagnostic Tests (MDT)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/08/2023 11/16/2023 - N/A Currently in Effect You are here
12/26/2019 10/24/2019 - 11/15/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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