SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: SMPD1 Genetic Testing

A54285

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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
A54285
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
11/21/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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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CMS National Coverage Policy

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Article Guidance

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

 

Response To Comments

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Coding Information

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Revenue Codes

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CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

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Group 1 Codes
Code Description
81330 SMPD1 (SPHINGOMYELIN PHOSPHODIESTERASE 1, ACID LYSOSOMAL) (EG, NIEMANN-PICK DISEASE, TYPE A) GENE ANALYSIS, COMMON VARIANTS (EG, R496L, L302P, FSP330)

Group 2

(1 Code)
Group 2 Paragraph

CPT® codes that are also referenced in other articles

Group 2 Codes
Code Description
81412 ASHKENAZI JEWISH ASSOCIATED DISORDERS (EG, BLOOM SYNDROME, CANAVAN DISEASE, CYSTIC FIBROSIS, FAMILIAL DYSAUTONOMIA, FANCONI ANEMIA GROUP C, GAUCHER DISEASE, TAY-SACHS DISEASE), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 9 GENES, INCLUDING ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, AND SMPD1
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CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

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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

Group 1

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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

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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 R12

Revision Effective: 01/02/2020
Revision Explanation: Under CPT/HCPCS Codes Group 1: Codes the description was revised for 81130. 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.

01/02/2020 R11

Revision Effective: 01/02/2020
Revision Explanation: 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 R10

Revision Effective: N/A
Revision Explanation: Annual review no changes made.

10/31/2019 R9

Revision Effective date: 10/31/2019
Revision Explanation: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.

10/03/2019 R8

Revision Effective date: 10/03/2019
Revision Explanation: Converted article into new billing and coding article format.

01/01/2019 R7

Revision Effective date: 01/01/2019
Revision Explanation: Removed 81403 from this article as new code 81412 replaces with annual HCPCS update.

10/01/2015 R6

Revision Effective date: N/A
Revision Explanation: Annual review no changes made.

10/01/2015 R5

Revision Effective date: N/A
Revision Explanation: Annual review no changes made

10/01/2015 R4 Revision Effective date: N/A
Revision Explanation: Annual review no changes made.
10/01/2015 R3 Revision Effective: N/A
Revision Explanation: Annual review no changes made.
10/01/2015 R2 R1
Revision Effective:10/01/2015
Revision Explanation: Changed MoPath to MolDX .
10/01/2015 R1 Revision Effective: N/A
Revision Explanation: Added Part A loop information.
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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
L36021 - MolDX: Molecular Diagnostic Tests (MDT)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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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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Public Versions
Updated On Effective Dates Status
11/15/2023 11/22/2023 - N/A Currently in Effect View
02/01/2023 01/01/2023 - 11/21/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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