The following coding and billing guidance is to be used with its associated Local coverage determination.
MAMMAPRINT™, an FDA cleared in vitro microarray diagnostic test that uses gene expression profiling to analyze the gene activity of the identified tumor, has been assigned a unique identifier.
MAMMAPRINTTM is a qualitative in vitro diagnostic test service, performed in a single laboratory, using the gene expression profile of FFPE breast cancer tissue samples to assess a patients' risk for distant metastasis.
MAMMAPRINT was prospectively validated in the 6,693 patient MINDACT trial in early stage breast cancer, <5cm up to 3 positive lymph nodes and independent of receptor status.
To bill for MAMMAPRINT™ services, submit the following claim information:
- Enter “1” in the Days/Unit field
- For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
- 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
Note: Noridian expects this test may be performed upon occasion twice per patient lifetime for bilateral disease. Should a patient experience an additional occurrence, coverage may be considered with supporting documentation through the appeal process.