LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: CDH1 Genetic Testing

A54878

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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.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A54878
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: CDH1 Genetic Testing
Article Type
Billing and Coding
Original Effective Date
01/22/2016
Revision Effective Date
11/16/2023
Revision Ending Date
N/A
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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Article Guidance

Article Text

CDH1 testing is utilized in patients with specified cancers as an adjunctive test.  CDH1 testing has also been recommended as a screening test for other cancers. However, screening for individuals at risk for cancer is not a Medicare benefit and is statutorily excluded.

To receive a CDH1 test denial, please submit the following claim information:

  • CPT® 81406 - CDH1, full gene sequence
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    • For a voluntary issued ABN, append with GX modifier
    • To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  • Enter the appropriate DEX Z-codeTM 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
    • Box 19 for paper claim
  • Enter the appropriate DEX-Z-codeTM identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:
    • Line SV202-7 for 8371 electronic claim
    • Block 80 for paper claim


In rare cases in which HDGC is suspected in a Medicare beneficiary, MolDX will review the documentation on a case-by-case basis.

Response To Comments

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Coding Information

Bill Type Codes

Code Description
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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
81406 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 7 (EG, ANALYSIS OF 11-25 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 26-50 EXONS, CYTOGENOMIC ARRAY ANALYSIS FOR NEOPLASIA)
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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

Group 1

(1 Code)
Group 1 Paragraph

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Group 1 Codes
Code Description
XX000 Not Applicable
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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.

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
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
11/16/2023 R11

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

02/02/2023 R10

Revision Effective: 02/02/2023

Revision Explanation: Annual review no changes made.

09/23/2021 R9

Revision Effective: 09/23/2021

Revision Explanation: Annual review no changes made.

11/21/2019 R8

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

11/21/2019 R7

Revision Effective Date: 11/21/2019
Revision Explanation: Added registered trademark through article text behind CPT.

11/21/2019 R6

Revision Effective Date: 11/21/2019
Revision Explanation: Removed guidelines from the title and in article test removed sentence for selecting diagnosis and reference information. added GX and GY to the modifier section.

10/03/2019 R5

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

06/07/2018 R4

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

06/07/2018 R3

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

06/07/2018 R2

Revision Effective:06/07/2018

Revision Explanation: Revised the opening paragraph for clarification.

 

05/23/2018 R1

R1

Revision Effective:05/23/2018

Revision Explanation: Added DEX Z-Code in front of identifier for the fourth bullet.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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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
11/08/2023 11/16/2023 - N/A Currently in Effect You are here
01/27/2023 02/02/2023 - 11/15/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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