Local Coverage Article Billing and Coding

Billing and Coding: Lab: Bladder/Urothelial Tumor Markers

A55029

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A55029
Article Title
Billing and Coding: Lab: Bladder/Urothelial Tumor Markers
Article Type
Billing and Coding
Original Effective Date
05/16/2017
Revision Effective Date
02/11/2021
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 2022 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 © 2022 American Dental Association. All rights reserved.

Copyright © 2022, 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.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

CMS Internet-Only Manual, Pub 100-4, 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 Lab: Bladder/Urothelial Tumor Markers (L36680).

Noridian will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion™ Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion™ Bladder Kit services may only be billed by a CLIA certified lab.

To bill UroVysion™ Bladder Kit services, submit the following claim information:

  • Select CPT® code 88120 or 88121 as appropriate
  • 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
    • Box 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

Laboratories reporting only the technical component for a UroVysion™ service should append the appropriate code 88120 or 88121 with the TC modifier.

All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.

  • Select CPT® code 88120 or 88121 as appropriate
  • 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
    • Box 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.

To register a test for a DEX Z-Code identifier, follow the registration process outlined in the MolDX Test Registration article located on the MolDX site. Once an identifier has been assigned, submit a technical assessment (TA) request as documented on the MolDX site TA Process.

Note: Physicians may NOT submit claims for a code 88120 and 88121 professional component when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report an interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.

To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:

  • Select the appropriate CPT® code
  • Enter 1 unit of service (UOS)
  • Select the appropriate ICD-10 code

Coding Information

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
86294 IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR SEMIQUANTITATIVE (EG, BLADDER TUMOR ANTIGEN)
86316 IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE (EG, CA 50, 72-4, 549), EACH
86386 NUCLEAR MATRIX PROTEIN 22 (NMP22), QUALITATIVE
88120 CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR PROBES, EACH SPECIMEN; MANUAL
88121 CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR PROBES, EACH SPECIMEN; USING COMPUTER-ASSISTED TECHNOLOGY

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
TC TECHNICAL COMPONENT; UNDER CERTAIN CIRCUMSTANCES, A CHARGE MAY BE MADE FOR THE TECHNICAL COMPONENT ALONE; UNDER THOSE CIRCUMSTANCES THE TECHNICAL COMPONENT CHARGE IS IDENTIFIED BY ADDING MODIFIER 'TC' TO THE USUAL PROCEDURE NUMBER; TECHNICAL COMPONENT CHARGES ARE INSTITUTIONAL CHARGES AND NOT BILLED SEPARATELY BY PHYSICIANS; HOWEVER, PORTABLE X-RAY SUPPLIERS ONLY BILL FOR TECHNICAL COMPONENT AND SHOULD UTILIZE MODIFIER TC; THE CHARGE DATA FROM PORTABLE X-RAY SUPPLIERS WILL THEN BE USED TO BUILD CUSTOMARY AND PREVAILING PROFILES

ICD-10-CM Codes that Support Medical Necessity

Group 1

(42 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.7 Malignant neoplasm of urachus
C67.8 Malignant neoplasm of overlapping sites of bladder
C67.9 Malignant neoplasm of bladder, unspecified
C7A.010 Malignant carcinoid tumor of the duodenum
C7A.011 Malignant carcinoid tumor of the jejunum
C7A.012 Malignant carcinoid tumor of the ileum
C7A.020 Malignant carcinoid tumor of the appendix
C7A.021 Malignant carcinoid tumor of the cecum
C7A.022 Malignant carcinoid tumor of the ascending colon
C7A.023 Malignant carcinoid tumor of the transverse colon
C7A.024 Malignant carcinoid tumor of the descending colon
C7A.025 Malignant carcinoid tumor of the sigmoid colon
C7A.026 Malignant carcinoid tumor of the rectum
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7A.091 Malignant carcinoid tumor of the thymus
C7A.092 Malignant carcinoid tumor of the stomach
C7A.093 Malignant carcinoid tumor of the kidney
C7A.098 Malignant carcinoid tumors of other sites
C7A.8 Other malignant neuroendocrine tumors
C7B.01 Secondary carcinoid tumors of distant lymph nodes
C7B.02 Secondary carcinoid tumors of liver
C7B.03 Secondary carcinoid tumors of bone
C7B.04 Secondary carcinoid tumors of peritoneum
C7B.09 Secondary carcinoid tumors of other sites
C7B.8 Other secondary neuroendocrine tumors
D09.0 Carcinoma in situ of bladder
D41.4 Neoplasm of uncertain behavior of bladder
D49.4 Neoplasm of unspecified behavior of bladder
E34.0 Carcinoid syndrome
R31.0 Gross hematuria
R31.1 Benign essential microscopic hematuria
R31.21* Asymptomatic microscopic hematuria
R31.29* Other microscopic hematuria
Z78.9* Other specified health status
Z85.51 Personal history of malignant neoplasm of bladder
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

R31.2 (before October 1, 2016) and R31.21 or R31.29 (effective October 1, 2016) are to be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis.

Z78.9 To be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis.

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Additional ICD-10 Information

N/A

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.

CodeDescription
999x Not Applicable

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.

99999


N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
02/11/2021 R6

This article is being revised to correct diagnosis codes. R31.9 was removed as noted in revision history 5. R31.1 was added back in as was deleted in error.

02/11/2021 R5

Under Article Text inserted UroVysion™ where applicable. In paragraphs 3 and 5 revised 1st bullet points to read "Select CPT® code 88120 or 88121 as appropriate," and 2nd and 3rd bullet points to read "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:". Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted C7A.00, C7A.019, C7A.029, C7A.094, C7A.095, C7A.096, C7B.00, C78.00 and R31.9. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the article.

10/01/2019 R4

10/01/2019: This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Lab: Bladder/Urothelial Tumor Markers L36680 LCD and placed in this article.

Moved all verbiage in the ICD-10 Codes that Support Medical Necessity Group 1: Paragraph section to the Group 1: Medical Necessity ICD-10 Codes Asterisk Explanation section. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes placed an asterisk by ICD-10 Codes R31.21, R31.29 and Z78.9. Under CPT/HCPCS Modifiers added modifier TC. CPT® was inserted throughout the article where applicable.

10/01/2019 R3

Converted to Billing and Coding article type.

Changed name from "MolDX: Bladder Tumor Marker FISH Billing and Coding Guidelines" to "Billing and Coding: Lab: Bladder/Urothelial Tumor Markers."

10/01/2017 R2

R2-Added MolDX in title, added coding instructions for all other services that meet the code 88120 or 88121by any provider type and specified "identifier" as DEX Z-Code™ identifier in the test registration paragraph.

05/16/2017 R1

Added billing information for Part A and clarified it for Part B.

Associated Documents

Related Local Coverage Documents
LCDs
L36680 - Lab: Bladder/Urothelial Tumor Markers
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
02/23/2021 02/11/2021 - N/A Currently in Effect You are here
02/05/2021 02/11/2021 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • UroVysion®
  • FISH
  • DEX Z-Code™
  • Coding
  • Billing