Draft Local Coverage Article Billing and Coding

Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing

DA57290

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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.

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General Information

Source Article ID
A57290
Draft Article ID
DA57290
Draft Article Title
Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing
Article Type
Billing and Coding
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CMS National Coverage Policy

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

CMS Internet-Only Manual Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §Section 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 MolDX: Melanoma Risk Stratification Molecular Testing.

To report a molecular diagnostic service, please submit the following claim information:

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

Covered tests:

The DecisionDx-Melanoma test is coveredas per the MolDX: Melanoma Risk Stratification Molecular Testing policy, when the following additional conditions are met:

  1. Patients diagnosed with cutaneous melanoma ≥ 0.3 mm without distant metastases in Breslow thickness where additional risk stratification information beyond anatomic and pathologic staging will influence management decisions regarding the following:
    • Sentinel Lymph Node Biopsy decision (T1-T2 only)
    • Appropriateness of adjuvant therapy
    • Determining the appropriate level of follow up, imaging, and referrals
  2. Patients diagnosed with cutaneous melanoma < 0.3 mm in Breslow thickness being considered for sentinel lymph node biopsy:
    • in whom there is significant uncertainty about the adequacy of microstaging (positive deep margin), or
    • with other adverse features (e.g. very high mitotic index [≥2/mm2], lymphovascular invasion, or a combination of these factors)

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
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Group 1 Codes
CodeDescription
81529 ONCOLOGY (CUTANEOUS MELANOMA), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 31 GENES (28 CONTENT AND 3 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS RECURRENCE RISK, INCLUDING LIKELIHOOD OF SENTINEL LYMPH NODE METASTASIS
81599 UNLISTED MULTIANALYTE ASSAY WITH ALGORITHMIC ANALYSIS

CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(24 Codes)
Group 1 Paragraph

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Group 1 Codes
CodeDescription
C43.0 Malignant melanoma of lip
C43.10 Malignant melanoma of unspecified eyelid, including canthus
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C43.20 Malignant melanoma of unspecified ear and external auricular canal
C43.21 Malignant melanoma of right ear and external auricular canal
C43.22 Malignant melanoma of left ear and external auricular canal
C43.30 Malignant melanoma of unspecified part of face
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.51 Malignant melanoma of anal skin
C43.52 Malignant melanoma of skin of breast
C43.59 Malignant melanoma of other part of trunk
C43.60 Malignant melanoma of unspecified upper limb, including shoulder
C43.61 Malignant melanoma of right upper limb, including shoulder
C43.62 Malignant melanoma of left upper limb, including shoulder
C43.70 Malignant melanoma of unspecified lower limb, including hip
C43.71 Malignant melanoma of right lower limb, including hip
C43.72 Malignant melanoma of left lower limb, including hip
C43.8 Malignant melanoma of overlapping sites of skin
C43.9 Malignant melanoma of skin, unspecified

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

Group 1

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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.

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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

Group 1

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Group 1 Codes

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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
05/11/2021 N/A - N/A N/A You are here

Keywords

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