The following coding and billing guidance is to be used with its associated Local coverage determination.
The MolDX Team has completed the Afirma assessment and determined that the test meets criteria for analytical and clinical validity, and clinical utility as a reasonable and necessary Medicare benefit. Effective 10/01/2015, MolDX will reimburse Afirma services for patients with the following conditions (patient must have 1 and 2):
1. Patients with one or more thyroid nodules with a history or characteristics suggesting malignancy such as:
- Nodule growth over time
- Family history of thyroid cancer
- Hoarseness, difficulty swallowing or breathing
- History of exposure to ionizing radiationHard nodule compared with rest of gland consistency
- Presence of cervical adenopathy
2. Have an indeterminate follicular pathology on fine needle aspiration
MolDX expects this test will be performed once per patient lifetime. Should the unlikely situation of a second, unrelated thyroid nodule with indeterminate pathology occur, coverage may be considered upon appeal with support documentation.
To report an Afirma service, submit the following claim information:
- Select the appropriate CPT® code.
- Select the appropriate ICD-10-CM diagnosis
- Enter the DEX Z-Code™ identifier in the comment/narrative field for the following Part B claim field/types:
- Loop 2400 or SV101-7 for the 5010A1 837P
- Item 19 for paper claim
- Enter the DEX Z-Code™ identifier 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