Local Coverage Article Billing and Coding

Billing and Coding: Genetic Testing for Lynch Syndrome


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Article ID
Article Title
Billing and Coding: Genetic Testing for Lynch Syndrome
Article Type
Billing and Coding
Original Effective Date
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Revision Ending Date
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  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34912 Genetic Testing for Lynch Syndrome. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

It has been recognized that there is some variation in the order of testing based on tissue availability, prevalence, patient history, test availability, testing turn-around time and patient treatment schedule. However, routine MMR germ-line mutation testing is not expected prior to appropriate screening (IHC/MSI). When MSI/IHC testing cannot be performed or is contradictory, claims for MMR germ-line testing exemptions will require the addition of the -KX modifier with the reported Current Procedural Terminology (CPT) code. The -KX modifier specifies that the “Requirements specified in the medical policy have been met. Documentation on file." Documentation is expected to be available upon request.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 

Coding Information


Group 1

(14 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

The following CPT codes associated with the services outlined in this Billing and Coding Article will not have diagnosis code limitations applied at this time: 0130U, 81210, 81301, 81403, 81435, 81479, 88341, 88342 and 88344.

Group 1 Codes
81288 Mlh1 gene
81292 Mlh1 gene full seq
81293 Mlh1 gene known variants
81294 Mlh1 gene dup/delete variant
81295 Msh2 gene full seq
81296 Msh2 gene known variants
81297 Msh2 gene dup/delete variant
81298 Msh6 gene full seq
81299 Msh6 gene known variants
81300 Msh6 gene dup/delete variant
81317 Pms2 gene full seq analysis
81318 Pms2 known familial variants
81319 Pms2 gene dup/delet variants
0238U Onc lnch syn gen dna seq aly

CPT/HCPCS Modifiers


ICD-10-CM Codes that Support Medical Necessity

Group 1

(108 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319 and 0238U.

Group 1 Codes
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C16.9 Malignant neoplasm of stomach, unspecified
C17.0 Malignant neoplasm of duodenum
C17.1 Malignant neoplasm of jejunum
C17.2 Malignant neoplasm of ileum
C17.3 Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C17.9 Malignant neoplasm of small intestine, unspecified
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C22.0 Liver cell carcinoma
C22.1 Intrahepatic bile duct carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C24.0 Malignant neoplasm of extrahepatic bile duct
C24.9 Malignant neoplasm of biliary tract, unspecified
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C54.0 Malignant neoplasm of isthmus uteri
C54.1 Malignant neoplasm of endometrium
C54.2 Malignant neoplasm of myometrium
C54.3 Malignant neoplasm of fundus uteri
C54.8 Malignant neoplasm of overlapping sites of corpus uteri
C54.9 Malignant neoplasm of corpus uteri, unspecified
C55 Malignant neoplasm of uterus, part unspecified
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C56.9 Malignant neoplasm of unspecified ovary
C57.00 Malignant neoplasm of unspecified fallopian tube
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
C57.10 Malignant neoplasm of unspecified broad ligament
C57.11 Malignant neoplasm of right broad ligament
C57.12 Malignant neoplasm of left broad ligament
C57.20 Malignant neoplasm of unspecified round ligament
C57.21 Malignant neoplasm of right round ligament
C57.22 Malignant neoplasm of left round ligament
C57.3 Malignant neoplasm of parametrium
C57.4 Malignant neoplasm of uterine adnexa, unspecified
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C66.1 Malignant neoplasm of right ureter
C66.2 Malignant neoplasm of left ureter
C66.9 Malignant neoplasm of unspecified ureter
C68.8 Malignant neoplasm of overlapping sites of urinary organs
C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of cerebral ventricle
C71.6 Malignant neoplasm of cerebellum
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of overlapping sites of brain
C71.9 Malignant neoplasm of brain, unspecified
D12.0 Benign neoplasm of cecum
D12.1 Benign neoplasm of appendix
D12.2 Benign neoplasm of ascending colon
D12.3 Benign neoplasm of transverse colon
D12.4 Benign neoplasm of descending colon
D12.5 Benign neoplasm of sigmoid colon
D12.6 Benign neoplasm of colon, unspecified
K63.5 Polyp of colon
L85.3 Xerosis cutis
Z85.00* Personal history of malignant neoplasm of unspecified digestive organ
Z85.038* Personal history of other malignant neoplasm of large intestine
Z85.048* Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.42* Personal history of malignant neoplasm of other parts of uterus
Z85.43* Personal history of malignant neoplasm of ovary
Z85.53* Personal history of malignant neoplasm of renal pelvis
Z85.54* Personal history of malignant neoplasm of ureter
Z85.59* Personal history of malignant neoplasm of other urinary tract organ
Z85.841* Personal history of malignant neoplasm of brain
Z86.010* Personal history of colonic polyps
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

* Diagnosis codes Z85.00, Z85.038, Z85.048, Z85.42, Z85.43, Z85.53, Z85.54, Z85.59, Z85.841 and Z86.010 should not be billed as the primary diagnosis.

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
XX000 Not Applicable

ICD-10-PCS Codes


Additional ICD-10 Information


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.

999x Not Applicable

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.

99999 Not Applicable

Other Coding Information


Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2021 R2

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has been added to the article: C56.3 in Group 1 Codes. Minor formatting changes have been made.

01/01/2021 R1

Article revised and published on 02/11/2021 effective for dates of service on and after 01/01/2021 to reflect the Annual HCPCS/CPT Code Updates. CPT code 0238U has been added to the CPT/HCPCS Code Group 1 and to the ICD-10 Codes that support medical necessity Group 1 Paragraph. CPT code 81288 has undergone either a short description and/or long description change. Depending on which description is used in this article, there may not be any change in how the code displays. Minor formatting changes were made throughout the article.

Associated Documents

Related Local Coverage Documents
L34912 - Genetic Testing for Lynch Syndrome
Related National Coverage Documents
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