FUTURE LCD Reference Article Billing and Coding Article

Billing and Coding: Genetic Testing in Oncology: Specific Tests

A59125

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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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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A59125
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Genetic Testing in Oncology: Specific Tests
Article Type
Billing and Coding
Original Effective Date
07/17/2023
Revision Effective Date
04/24/2025
Revision Ending Date
N/A
Retirement Date
N/A

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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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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 Manuals (IOMs):

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 16, Section 10 Background, Section 40.8 Date of Service (DOS) for Clinical Laboratory and Pathology Specimens and Section 120.1 Negotiated Rulemaking Implementation
    • Chapter 18 Preventive and Screening Services
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 3 Verifying Potential Errors and Taking Corrective Actions

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.

Code of Federal Regulations (CFR) References:

  • CFR, Title 42, Subchapter B, Section 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions, Section 414.502 Definitions, Section 414.507 Payment for clinical diagnostic laboratory tests, and Section 414.510 Laboratory date of service for clinical laboratory and pathology specimens
  • CFR, Title 42, Subchapter G, Part 493 Laboratory Requirements
  • CFR, Title 42, Section 1395y(b)(1)(F) Limitation on beneficiary liability

Medicare National Correct Coding Initiative (NCCI) Policy Manual:

  • Chapter 10, Section F Molecular Pathology
  • Chapter 10, Section M Medically Unlikely Edits (MUEs)

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39365 Genetic Testing in Oncology: Specific Tests. Please refer to the LCD for reasonable and necessary requirements.

All instructions provided within the American Medical Association (AMA) Current Procedural Terminology (CPT) Codebook with rules and guidelines from the AMA’s CPT Editorial Panel and the Medicare NCCI Policy Manual must be followed when utilizing CPT codes for billing. Proper coding involves interpreting code descriptions provided by these sources as well as any associated parentheticals. The instructions below do not represent the full breadth or depth of instructions found in the CPT Codebook and the Medicare NCCI Policy Manual. Providers that bill Medicare are expected to follow all instructions found in these sources.

Coding Guidance


The following information should be reported on claims for UroVysion Bladder Kit services:

  • CPT code 88120 or 88121 as appropriate.
  • ‘UroVysion’ should be placed in the comment/narrative field for the following claim field/types:
    • Loop 2400, NTE02, or SV101-7 for the 5010A1 837P
    • Submit 'UroVysion' on an attachment to the claim form when submitting a paper claim.

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

Note: Physicians may not submit claims for the professional component of codes 88120 and 88121 when the interpretive information is provided by a lab technician or scientist.

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.

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(s) must describe the service performed.
  4. The medical record must demonstrate that the ordering clinician is responsible for the management of the patient’s cancer or substantiated suspicion of cancer.
  5. The medical record must include documentation to support an established diagnosis of cancer or a substantiated suspicion of cancer.
  6. The medical record must include documentation of how the test results will directly impact the management of the patient’s specific medical problem.
  7. The medical record must clearly document the communication and discussion of pre-test and post-test counseling and the risk associated with genetic testing.
  8. The medical record from the ordering clinician must clearly indicate all tests that are to be performed.

Response To Comments

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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

(19 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/HCPCS Group 1 codes: 88120 and 88121.

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
D09.0 Carcinoma in situ of bladder
D09.10 Carcinoma in situ of unspecified urinary organ
D09.19 Carcinoma in situ of other urinary organs
D49.4 Neoplasm of unspecified behavior of bladder
E85.89* Other amyloidosis
R31.0* Gross hematuria
R31.21* Asymptomatic microscopic hematuria
R31.29* Other microscopic hematuria
R31.9* Hematuria, unspecified
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: Use ICD-10-CM code E85.89, R31.0, R31.21, R31.29, or R31.9 with R82.89 to reflect abnormal cytological or histological findings in examination of urine that substantiate a suspicion of cancer.

Note: Use ICD-10 codes C67.0-C67.9, D09.0, D09.10, D09.19, or D49.4 as a stand-alone code for patients previously diagnosed with bladder cancer.

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

Group 1

Group 1 Paragraph

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

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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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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Other Coding Information

Group 1

Group 1 Paragraph

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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
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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
04/24/2025 R1

Article posted for notice on 01/09/2025 to become effective on 02/23/2025.
Draft article posted on 7/27/2023.

The Article effective date will be delayed by 60 days.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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Public Versions
Updated On Effective Dates Status
01/03/2025 04/24/2025 - N/A Future Effective You are here
05/24/2023 07/17/2023 - 04/23/2025 Currently in Effect View

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