Local Coverage Article Billing and Coding

Billing and Coding: MolDX: SMPD1 Genetic Testing

A55631

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A55631
Article Title
Billing and Coding: MolDX: SMPD1 Genetic Testing
Article Type
Billing and Coding
Original Effective Date
10/09/2017
Revision Effective Date
01/01/2023
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 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

N/A

Article Guidance

Article Text

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, Noridian has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, Noridian 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

 

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
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
CodeDescription
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

CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
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

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-PCS Codes

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.

N/A

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.

N/A


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
01/01/2023 R6

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 for dates on or after 01/01/2023.

01/01/2023 R5

Under Group I CPT/HCPS: 81330 descriptor was changed effective 01.01.2023.

12/17/2021 R4

Noridian has modified certain language in this article to mirror the language used presently by the MolDX team at Palmetto GBA as part of an annual review. Revision history dates and language may not exactly match the MolDX PGBA revision history. However, these revision do not change coverage or guidance.

12/01/2019 R3

CMS references were removed. 81403 is deleted effective 1/1/2019 for consistency with the MolDX Contractor. This deletion should have been noted prior to code migration required by CR 10901.

12/01/2019 R2

As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.

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. References were added to the CMS National Coverage Policy Section. 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.

10/09/2017 R1

Article is revised to add Part A claim filing information.

Associated Documents

Related Local Coverage Documents
LCDs
L36256 - MolDX: Molecular Diagnostic Tests (MDT)
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
01/26/2023 01/01/2023 - N/A Currently in Effect You are here
12/29/2022 01/01/2023 - N/A Superseded View
02/24/2022 12/17/2021 - 12/31/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A