SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: SMPD1 Genetic Testing

A53624

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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
N/A
Article ID
A53624
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: SMPD1 Genetic Testing
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A

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Article Text

Effective for dates of service on and after February 7, 2013.

Mutations found in sphingomyelin phosphodiesterase 1, (SMPD1) acid lysomal, are associated with Niemann-Pick Disease, characterized by acid sphingomyelinase (ASM) deficiency. For infants and children, SMPD1 genetic testing is used to confirm the clinical findings from blood tests to diagnose ASM. Genetic testing for adults is used to screen the population for potential carriers of the mutation. Therefore, the MolDX team has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, MolDX will also deny panels of tests that include a SMPD1 gene test as a statutorily excluded service.

To receive a SMPD1 test denial, please submit the following claim information:

  • CPT® code 81330- SMPD1, common variants
  • CPT® code 81412 – Ashkenazi Jewish Associated Disorders
    • For a voluntary issued ABN, append with GX modifier
    • To indicate a statutorily excluded service, append with a GY modifier. An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services

 

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Coding Information

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CPT/HCPCS Modifiers

Group 1

(2 Codes)
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Group 1 Codes
Code Description
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
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ICD-10-CM Codes that Support Medical Necessity

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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

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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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
01/01/2023 R8

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 81330. This is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of services on or after 1/1/2023.

Under Article Text removed verbiage regarding instructions on how to submit a DEX Z-code™ on claims. Formatting, punctuation, and typographical errors were corrected throughout the article. This revision is retroactive effective date for dates of services on or after 1/1/2023.

11/07/2019 R7

Under Article Text deleted the statement “Select the appropriate diagnosis for the patient”. Under CPT/HCPCS Codes Group 1: Codes deleted CPT® code 81412. Under CPT/HCPCS Codes Group 2: Paragraph added verbiage, “CPT® codes that are also referenced in other articles”. Under CPT/HCPCS Codes Group 2: Codes added CPT® code 81412. CPT® was inserted throughout the article where applicable.

10/31/2019 R6

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the title from “MolDX: SMPD1 Genetic Testing Coding and Billing Guidelines” to “Billing and Coding: MolDX: SMPD1 Genetic Testing”. Under Article Text removed the last paragraph. Under CPT/HCPCS Modifiers Group 1: Codes added modifiers GX, GY.

01/01/2019 R5

Deleted 81403 and added 81412 the article. Added all CPT code: 81330 and 81412 to CPT/HCPCS Codes Group 1. CPT code 81330 was previously in the article, but not in the CPT/HCPCS Codes Group 1 field. This change is due to the CPT/HCPCS 2019 Annual Update and is effective 1/1/19.

 

02/26/2018 R4 The Jurisdiction "J" Part A and Part B Contracts for Alabama (10111/10112), Georgia (10211/10212) and Tennessee (10311/10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these 6 contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 6 Part A and B contract numbers) have been completed in this revision.
10/26/2017 R3

Annual review completed. Added Part A contracts and DEX Z-Code identifier information.

10/29/2015 R2 Annual review completed. Replaced reference to Palmetto and/or Palmetto GBA with MolDX
10/29/2015 R1 Annual review completed, no changes needed
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L35025 - MolDX: Molecular Diagnostic Tests (MDT)
Related National Coverage Documents
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SAD Process URL 2
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Public Versions
Updated On Effective Dates Status
05/21/2024 01/01/2023 - 05/21/2024 Retired View
01/24/2023 01/01/2023 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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