Superseded Local Coverage Article Billing and Coding

Billing and Coding: Genetic Testing for Cardiovascular Disease


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Contractor Information

Article Information

General Information

Article ID
Article Title
Billing and Coding: Genetic Testing for Cardiovascular Disease
Article Type
Billing and Coding
Original Effective Date
Revision Effective Date
Revision Ending Date
Retirement Date
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 1, Section 60 Provider Billing of Non-covered Charges on Institutional Claims
    • Chapter 16, Laboratory Services
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI), Section Instructions for Codes with Modifiers (A/B MACs (B) Only), and Section 40 Clinical Diagnostic Laboratory Fee Schedule
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 3, Sections Diagnosis Code Requirements and Limitations of Liability Determinations

National Correct Coding Initiative (NCCI) Citation:

  • NCCI Policy Manual for Medicare Services,
    • Chapter 10, Pathology/Laboratory Services, (A) Introduction and (F) Molecular Pathology

Social Security Act (Title XVIII) Standard References:

  • 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.
  • Title XVIII of the Social Security Act, Section 1834A(d) This section addresses payment for new advanced diagnostic laboratory tests.

Code of Federal Register (CFR) References:

  • CFR, Title 42, Volume 2, Chapter IV, Part 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  • CFR, Title 42, Volume 3, Chapter IV, Part 414, Subpart G Payment for Clinical Diagnostic Laboratory Tests.
  • CFR, Title 42, Volume 3, Chapter IV, Part 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL39084 Genetic Testing for Cardiovascular Disease. Please refer to the LCD for reasonable and necessary requirements.

Tier 2 CPT code 81406 is not appropriate to report for cardiovascular genetic testing because there are no genes associated with CPT code 81406 that meet the ClinGen evidence standards.

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.

All limitations of the LCD apply.

No genes currently meet criteria for coverage as outlined in the LCD.

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.
  4. The medical record must demonstrate the treating clinician who is responsible for the cardiovascular disease management is the ordering clinician.
  5. The medical record must clearly document the communication and discussion of pre-test and post-test counseling and the risk associated with genetic testing.
  6. The medical record must demonstrate disease appropriate phenotyping to establish clinical diagnosis or suspected diagnosis for which the test results would directly impact the management of the patient’s condition.
  7. The clinical actionability of the gene-disease relationship for the patient must be documented in the medical record.

Coding Information


Group 1

(19 Codes)
Group 1 Paragraph

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

Consistent with the LCD, the following CPT codes are non-covered.

Group 1 Codes
81161 Dmd dup/delet analysis
81401 Mopath procedure level 2
81402 Mopath procedure level 3
81403 Mopath procedure level 4
81404 Mopath procedure level 5
81405 Mopath procedure level 6
81407 Mopath procedure level 8
81408 Mopath procedure level 9
81410 Aortic dysfunction/dilation
81411 Aortic dysfunction/dilation
81413 Car ion chnnlpath inc 10 gns
81414 Car ion chnnlpath inc 2 gns
81415 Exome sequence analysis
81416 Exome sequence analysis
81417 Exome re-evaluation
81439 Hrdtry cardmypy gene panel
81442 Noonan spectrum disorders
0119U Crd ceramides liq chrom plsm
0237U Car ion chnlpthy gen seq pnl

CPT/HCPCS Modifiers


ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

Due to non-coverage there are no ICD-10-CM Codes that support medical necessity at this time.

Group 1 Codes


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


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.


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.


Other Coding Information


Revision History Information


Associated Documents

Related National Coverage Documents
Statutory Requirements URLs
Rules and Regulations URLs
CMS Manual Explanations URLs
Other URLs
Public Versions
Updated On Effective Dates Status
07/14/2023 07/01/2023 - N/A Currently in Effect View
12/23/2021 01/30/2022 - 06/30/2023 Superseded View
12/10/2021 01/30/2022 - N/A Superseded You are here