SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Bladder/Urothelial Tumor Markers

A56471

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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
A56471
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Bladder/Urothelial Tumor Markers
Article Type
Billing and Coding
Original Effective Date
03/23/2017
Revision Effective Date
02/01/2024
Revision Ending Date
09/30/2024
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

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5 Jurisdiction of Laboratory Claims, §60.1.2 Independent Laboratory Specimen Drawing, §60.2 Travel Allowance

CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, §10 Reporting ICD Diagnosis and Procedure Codes

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36975).

CGS Administrators, LLC will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion™ Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion™ Bladder Kit services may only be billed by a CLIA certified lab.

To bill UroVysion™ Bladder Kit services, submit the following claim information:

  • Select CPT® code 88120 or 88121 as appropriate
  • Enter the appropriate 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 the appropriate 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

Laboratories reporting only the technical component for a UroVysion™ service should append the appropriate code 88120 or 88121 with the TC modifier.

All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.

  • Select CPT® code 88120 or 88121 as appropriate
  • Enter the appropriate 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 the appropriate 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

To register a test for a DEX Z-Code™ identifier, follow the registration process outlined in the MolDX Test Registration article located on the MolDX site. Once an identifier has been assigned, submit a Technical Assessment (TA) request as documented on the MolDX site TA Process.

Note: Physicians may NOT submit claims for a code 88120 and 88121 professional component when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.

To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:

  • Select the appropriate CPT® code
  • Enter 1 unit of service (UOS)
  • Select the appropriate ICD-10 code

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(42 Codes)
Group 1 Paragraph

R31.21 or R31.29 are to be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis.

 

Z78.9 To be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis.

Group 1 Codes
Code Description
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.7 Malignant neoplasm of urachus
C67.8 Malignant neoplasm of overlapping sites of bladder
C67.9 Malignant neoplasm of bladder, unspecified
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.098 Malignant carcinoid tumors of other sites
C7A.8 Other malignant neuroendocrine tumors
C7B.01 Secondary carcinoid tumors of distant lymph nodes
C7B.02 Secondary carcinoid tumors of liver
C7B.03 Secondary carcinoid tumors of bone
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
C7B.8 Other secondary neuroendocrine tumors
D09.0 Carcinoma in situ of bladder
D41.4 Neoplasm of uncertain behavior of bladder
D49.4 Neoplasm of unspecified behavior of bladder
E34.0 Carcinoid syndrome
R31.0 Gross hematuria
R31.1 Benign essential microscopic hematuria
R31.21* Asymptomatic microscopic hematuria
R31.29* Other microscopic hematuria
Z78.9* Other specified health status
Z85.51 Personal history of malignant neoplasm of bladder
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

Group 1: Medical Necessity ICD-10 Codes Asterisk Explanation

R31.2 (before October 1, 2016) and R31.21 or R31.29 (effective October 1, 2016) are to be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis.

Z78.9 To be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis.

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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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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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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

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
02/01/2024 R9

Revision Effective: 02/01/2024

Revision Explanation: Annual review, no changes were made. 

11/16/2023 R8

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

01/26/2023 R7

Revision Effective: 01/26/2023

Revision Explanation: Annual review, no changes were made.

02/03/2022 R6

Revision Effective: 02/03/2022

Revision Explanation: Annual review, no changes were made.

02/11/2021 R5

Revision Effective: 02/11/2021

Revision Explanation: Under Article Text inserted UroVysion™ where applicable. In paragraphs 3 and 5 revised 1st bullet points to read “Select CPT® code 88120 or 88121 as appropriate,” and 2nd and 3rd bullet points to read “Enter the appropriate DEX Z-CODE™ Identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:”. Under CPT/HCPCS Codes Group 1: Paragraph deleted the verbiage “CPT Codes”. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted C7A.00, C7A.019, C7A.029, C7A.094. C7A.095, C7A.096, C7B.00, C78.00, and R31.9. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the article.

10/31/2019 R4


Revision Effective: N/A

Revision Explanation: Annual Review, no changes made.

10/31/2019 R3

R3

Revision Effective: 10/31/2019

Revision Explanation: Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Lab: Special Histochemical Stains and Immunohistochemical Stains L35922 LCD and placed in this article.

09/19/2019 R2

R2

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

03/23/2017 R1

R1

Revision Effective: 03/23/2017

Revision Explanation: Corrected title to include urothelial.

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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
L36975 - Bladder/Urothelial Tumor Markers
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
09/09/2024 10/01/2024 - N/A Currently in Effect View
01/25/2024 02/01/2024 - 09/30/2024 Superseded You are here
11/07/2023 11/16/2023 - 01/31/2024 Superseded View
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