SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: PTCH1 Gene Testing

A54297

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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.
Superseded
To see the currently-in-effect version of this document, go to the section.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54297
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: PTCH1 Gene Testing
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

CPT codes, descriptions, and other data only are copyright 2023 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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CMS National Coverage Policy

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Article Guidance

Article Text

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

PTCH1 gene testing may be performed during the diagnosis of Nevoid Basal Cell Carcinoma Syndrome (NBCCS). Since the diagnosis of NBCCS is established using clinical diagnostic criteria and carrier testing is not a covered benefit, CGS Administrators, LLC have determined PTCH1 analysis is a statutorily excluded test.

To receive a PTCH1 analysis service denial, please submit the following claim information:

  • CPT code 81479
  • 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 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 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

 

Response To Comments

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1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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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

Group 1

Group 1 Paragraph

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Group 1 Codes

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

Group 1

Group 1 Paragraph

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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

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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

Group 1

Group 1 Paragraph

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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 R14

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

02/02/2023 R13

Revision Effective date: 02/02/2023
Revision Explanation: Annual review, no changes.

02/03/2022 R12

Revision Effective date: 02/03/2022
Revision Explanation: Annual review, corrected spacing within the Article Text section.

10/31/2019 R11

Revision Effective date: N/A
Revision Explanation: Annual review, updated contractor's name in the Article Text section.

10/31/2019 R10

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

10/31/2019 R9

Revision Effective date: 10-31-2019

Revision Explanation: This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the title from “MolDX: PTCH1 Gene Testing Coding and Billing Guidelines” to “Billing and Coding: MolDX: PTCH1 Gene Testing”. Under Article Text removed the last paragraph. Under CPT/HCPCS Codes Group 1: Codes added 81479. Under CPT/HCPCS Modifiers Group 1: Codes added modifiers GX and GY.

10/03/2019 R8

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

07/20/2017 R7

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

10/01/2015 R6

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

07/20/2017 R5

Revision Effective date: 07/20/2017
Revision Explanation: Added DEX Z-code in front of identifier.

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.
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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
04/25/2024 11/16/2023 - 04/25/2024 Retired View
11/07/2023 11/16/2023 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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