Superseded Local Coverage Article Billing and Coding

Billing and Coding: MolDX: BCR-ABL

A55600

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

Contractor Information

Article Information

General Information

Article ID
A55600
Article Title
Billing and Coding: MolDX: BCR-ABL
Article Type
Billing and Coding
Original Effective Date
12/01/2017
Revision Effective Date
11/01/2019
Revision Ending Date
02/09/2022
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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

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Article Guidance

Article Text

Breakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests (major, minor and other breakpoints). To report multiple tests assigned a single ID, submit CPT code 81479. This guideline includes the following CPT© code combinations:

  • 81206 and 81207
  • 81206, 81207, and 81208

CPT codes 81206, 81207, and 81208 may only be reported when performed as a single test.

Laboratories performing BCR-ABL translocation analysis by NGS must obtain a DEX™ Z-code identifier to differentiate NGS testing from non-NGS methods.

To submit a claim for BCR-ABL translocation analysis by NGS:

  • CPT 81479
  • Enter “1” in the Days/Unit field
  • Enter the DEX Z-Code™ identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:
    • Loop 2400/SV101-7 for the 5010A1 837P
    • Item 19 for CMS-1500 paper claim form
  • Enter the 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

 

Reimbursement is based on the number of reported gene(s) in small NGS panels. Tier 1 and/or Tier 2 individual biomarker CPT© codes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.

To report the FDA-approved MRDx BCR-ABL Test, use CPT code 0040U.

Coding Information

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
81206 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MAJOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE
81207 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; MINOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE
81208 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS; OTHER BREAKPOINT, QUALITATIVE OR QUANTITATIVE
81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE
0040U BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION ANALYSIS, MAJOR BREAKPOINT, QUANTITATIVE

CPT/HCPCS Modifiers

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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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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.

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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.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
11/01/2019 R2

Added 0040U effective 1/1/19, per the 2019 CPT/HCPCS Annual Update and consistency with the MolDX Contrctor and converted article to Billing and Coding Article type.

12/01/2017 R1

Article is revised to provide updated billing instructions and reimbursement information.

Associated Documents

Related National Coverage Documents
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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
02/10/2022 02/10/2022 - N/A Currently in Effect View
10/09/2019 11/01/2019 - 02/09/2022 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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