DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: Genetic Testing for Hereditary Thrombophilia

DA60272

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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
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Draft Article ID
DA60272
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: MolDX: Genetic Testing for Hereditary Thrombophilia
Article Type
Billing and Coding
Original Effective Date
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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 Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories

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 MolDX: Genetic Testing for Hereditary Thrombophilia DL40242.

Please submit the following claim information:

  • Select CPT® code 81240, 81241, 81479
  • 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(s).

NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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(98 Codes)
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Group 1 Codes
Code Description
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.93 Single subsegmental thrombotic pulmonary embolism without acute cor pulmonale
I26.94 Multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I27.82 Chronic pulmonary embolism
I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I67.6 Nonpyogenic thrombosis of intracranial venous system
I81 Portal vein thrombosis
I82.0 Budd-Chiari syndrome
I82.290 Acute embolism and thrombosis of other thoracic veins
I82.291 Chronic embolism and thrombosis of other thoracic veins
I82.3 Embolism and thrombosis of renal vein
I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity
I82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity
I82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral
I82.409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity
I82.411 Acute embolism and thrombosis of right femoral vein
I82.412 Acute embolism and thrombosis of left femoral vein
I82.413 Acute embolism and thrombosis of femoral vein, bilateral
I82.419 Acute embolism and thrombosis of unspecified femoral vein
I82.421 Acute embolism and thrombosis of right iliac vein
I82.422 Acute embolism and thrombosis of left iliac vein
I82.423 Acute embolism and thrombosis of iliac vein, bilateral
I82.429 Acute embolism and thrombosis of unspecified iliac vein
I82.431 Acute embolism and thrombosis of right popliteal vein
I82.432 Acute embolism and thrombosis of left popliteal vein
I82.433 Acute embolism and thrombosis of popliteal vein, bilateral
I82.439 Acute embolism and thrombosis of unspecified popliteal vein
I82.441 Acute embolism and thrombosis of right tibial vein
I82.442 Acute embolism and thrombosis of left tibial vein
I82.443 Acute embolism and thrombosis of tibial vein, bilateral
I82.449 Acute embolism and thrombosis of unspecified tibial vein
I82.451 Acute embolism and thrombosis of right peroneal vein
I82.452 Acute embolism and thrombosis of left peroneal vein
I82.453 Acute embolism and thrombosis of peroneal vein, bilateral
I82.459 Acute embolism and thrombosis of unspecified peroneal vein
I82.461 Acute embolism and thrombosis of right calf muscular vein
I82.462 Acute embolism and thrombosis of left calf muscular vein
I82.463 Acute embolism and thrombosis of calf muscular vein, bilateral
I82.469 Acute embolism and thrombosis of unspecified calf muscular vein
I82.491 Acute embolism and thrombosis of other specified deep vein of right lower extremity
I82.492 Acute embolism and thrombosis of other specified deep vein of left lower extremity
I82.493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral
I82.499 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity
I82.4Y1 Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity
I82.4Y2 Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity
I82.4Y3 Acute embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral
I82.4Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity
I82.4Z1 Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity
I82.4Z3 Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral
I82.4Z9 Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity
I82.501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity
I82.502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity
I82.503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral
I82.509 Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity
I82.511 Chronic embolism and thrombosis of right femoral vein
I82.512 Chronic embolism and thrombosis of left femoral vein
I82.513 Chronic embolism and thrombosis of femoral vein, bilateral
I82.519 Chronic embolism and thrombosis of unspecified femoral vein
I82.521 Chronic embolism and thrombosis of right iliac vein
I82.522 Chronic embolism and thrombosis of left iliac vein
I82.523 Chronic embolism and thrombosis of iliac vein, bilateral
I82.529 Chronic embolism and thrombosis of unspecified iliac vein
I82.531 Chronic embolism and thrombosis of right popliteal vein
I82.532 Chronic embolism and thrombosis of left popliteal vein
I82.533 Chronic embolism and thrombosis of popliteal vein, bilateral
I82.539 Chronic embolism and thrombosis of unspecified popliteal vein
I82.541 Chronic embolism and thrombosis of right tibial vein
I82.542 Chronic embolism and thrombosis of left tibial vein
I82.543 Chronic embolism and thrombosis of tibial vein, bilateral
I82.551 Chronic embolism and thrombosis of right peroneal vein
I82.552 Chronic embolism and thrombosis of left peroneal vein
I82.553 Chronic embolism and thrombosis of peroneal vein, bilateral
I82.559 Chronic embolism and thrombosis of unspecified peroneal vein
I82.561 Chronic embolism and thrombosis of right calf muscular vein
I82.562 Chronic embolism and thrombosis of left calf muscular vein
I82.563 Chronic embolism and thrombosis of calf muscular vein, bilateral
I82.569 Chronic embolism and thrombosis of unspecified calf muscular vein
I82.591 Chronic embolism and thrombosis of other specified deep vein of right lower extremity
I82.592 Chronic embolism and thrombosis of other specified deep vein of left lower extremity
I82.593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral
I82.599 Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity
I82.5Y1 Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity
I82.5Y2 Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity
I82.5Y3 Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral
I82.5Y9 Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity
I82.5Z1 Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity
I82.5Z2 Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity
I82.5Z3 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral
I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity
I82.90 Acute embolism and thrombosis of unspecified vein
I82.91 Chronic embolism and thrombosis of unspecified vein
K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified
K55.1 Chronic vascular disorders of intestine
Z86.711 Personal history of pulmonary embolism
Z86.718 Personal history of other venous thrombosis and embolism
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS Codes

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Additional ICD-10 Information

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Bill Type Codes

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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

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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