SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: Blood Product Molecular Antigen Typing

A57124

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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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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57124
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: Blood Product Molecular Antigen Typing
Article Type
Billing and Coding
Original Effective Date
12/06/2020
Revision Effective Date
10/01/2023
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 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

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

 

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Blood Product Molecular Antigen Typing.

Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.

The individual codes 0180U-0201U, 0221U and 0222U and codes 81105-81112 are also germline tests. These will be noncovered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.

To report a Blood Product Molecular Antigen Typing service, please submit the following claim information:

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

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(3 Codes)
Group 1 Paragraph

The use of 81403 does not automatically imply coverage

Group 1 Codes
Code Description
81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 4 (EG, ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, ANALYSIS OF >10 AMPLICONS USING MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION SCANNING OR DUPLICATION/DELETION VARIANTS OF 2-5 EXONS)
0001U RED BLOOD CELL ANTIGEN TYPING, DNA, HUMAN ERYTHROCYTE ANTIGEN GENE ANALYSIS OF 35 ANTIGENS FROM 11 BLOOD GROUPS, UTILIZING WHOLE BLOOD, COMMON RBC ALLELES REPORTED
0084U RED BLOOD CELL ANTIGEN TYPING, DNA, GENOTYPING OF 10 BLOOD GROUPS WITH PHENOTYPE PREDICTION OF 37 RED BLOOD CELL ANTIGENS

Group 2

(32 Codes)
Group 2 Paragraph

These codes are non-covered

Group 2 Codes
Code Description
81105 HUMAN PLATELET ANTIGEN 1 GENOTYPING (HPA-1), ITGB3 (INTEGRIN, BETA 3 [PLATELET GLYCOPROTEIN IIIA], ANTIGEN CD61 [GPIIIA]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-1A/B (L33P)
81106 HUMAN PLATELET ANTIGEN 2 GENOTYPING (HPA-2), GP1BA (GLYCOPROTEIN IB [PLATELET], ALPHA POLYPEPTIDE [GPIBA]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-2A/B (T145M)
81107 HUMAN PLATELET ANTIGEN 3 GENOTYPING (HPA-3), ITGA2B (INTEGRIN, ALPHA 2B [PLATELET GLYCOPROTEIN IIB OF IIB/IIIA COMPLEX], ANTIGEN CD41 [GPIIB]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-3A/B (I843S)
81108 HUMAN PLATELET ANTIGEN 4 GENOTYPING (HPA-4), ITGB3 (INTEGRIN, BETA 3 [PLATELET GLYCOPROTEIN IIIA], ANTIGEN CD61 [GPIIIA]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-4A/B (R143Q)
81109 HUMAN PLATELET ANTIGEN 5 GENOTYPING (HPA-5), ITGA2 (INTEGRIN, ALPHA 2 [CD49B, ALPHA 2 SUBUNIT OF VLA-2 RECEPTOR] [GPIA]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT (EG, HPA-5A/B [K505E])
81110 HUMAN PLATELET ANTIGEN 6 GENOTYPING (HPA-6W), ITGB3 (INTEGRIN, BETA 3 [PLATELET GLYCOPROTEIN IIIA, ANTIGEN CD61] [GPIIIA]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-6A/B (R489Q)
81111 HUMAN PLATELET ANTIGEN 9 GENOTYPING (HPA-9W), ITGA2B (INTEGRIN, ALPHA 2B [PLATELET GLYCOPROTEIN IIB OF IIB/IIIA COMPLEX, ANTIGEN CD41] [GPIIB]) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-9A/B (V837M)
81112 HUMAN PLATELET ANTIGEN 15 GENOTYPING (HPA-15), CD109 (CD109 MOLECULE) (EG, NEONATAL ALLOIMMUNE THROMBOCYTOPENIA [NAIT], POST-TRANSFUSION PURPURA), GENE ANALYSIS, COMMON VARIANT, HPA-15A/B (S682Y)
0180U RED CELL ANTIGEN (ABO BLOOD GROUP) GENOTYPING (ABO), GENE ANALYSIS SANGER/CHAIN TERMINATION/CONVENTIONAL SEQUENCING, ABO (ABO, ALPHA 1-3-N-ACETYLGALACTOSAMINYLTRANSFERASE AND ALPHA 1-3-GALACTOSYLTRANSFERASE) GENE, INCLUDING SUBTYPING, 7 EXONS
0181U RED CELL ANTIGEN (COLTON BLOOD GROUP) GENOTYPING (CO), GENE ANALYSIS, AQP1 (AQUAPORIN 1 [COLTON BLOOD GROUP]) EXON 1
0182U RED CELL ANTIGEN (CROMER BLOOD GROUP) GENOTYPING (CROM), GENE ANALYSIS, CD55 (CD55 MOLECULE [CROMER BLOOD GROUP]) EXONS 1-10
0183U RED CELL ANTIGEN (DIEGO BLOOD GROUP) GENOTYPING (DI), GENE ANALYSIS, SLC4A1 (SOLUTE CARRIER FAMILY 4 MEMBER 1 [DIEGO BLOOD GROUP]) EXON 19
0184U RED CELL ANTIGEN (DOMBROCK BLOOD GROUP) GENOTYPING (DO), GENE ANALYSIS, ART4 (ADP-RIBOSYLTRANSFERASE 4 [DOMBROCK BLOOD GROUP]) EXON 2
0185U RED CELL ANTIGEN (H BLOOD GROUP) GENOTYPING (FUT1), GENE ANALYSIS, FUT1 (FUCOSYLTRANSFERASE 1 [H BLOOD GROUP]) EXON 4
0186U RED CELL ANTIGEN (H BLOOD GROUP) GENOTYPING (FUT2), GENE ANALYSIS, FUT2 (FUCOSYLTRANSFERASE 2) EXON 2
0187U RED CELL ANTIGEN (DUFFY BLOOD GROUP) GENOTYPING (FY), GENE ANALYSIS, ACKR1 (ATYPICAL CHEMOKINE RECEPTOR 1 [DUFFY BLOOD GROUP]) EXONS 1-2
0188U RED CELL ANTIGEN (GERBICH BLOOD GROUP) GENOTYPING (GE), GENE ANALYSIS, GYPC (GLYCOPHORIN C [GERBICH BLOOD GROUP]) EXONS 1-4
0189U RED CELL ANTIGEN (MNS BLOOD GROUP) GENOTYPING (GYPA), GENE ANALYSIS, GYPA (GLYCOPHORIN A [MNS BLOOD GROUP]) INTRONS 1, 5, EXON 2
0190U RED CELL ANTIGEN (MNS BLOOD GROUP) GENOTYPING (GYPB), GENE ANALYSIS, GYPB (GLYCOPHORIN B [MNS BLOOD GROUP]) INTRONS 1, 5, PSEUDOEXON 3
0191U RED CELL ANTIGEN (INDIAN BLOOD GROUP) GENOTYPING (IN), GENE ANALYSIS, CD44 (CD44 MOLECULE [INDIAN BLOOD GROUP]) EXONS 2, 3, 6
0192U RED CELL ANTIGEN (KIDD BLOOD GROUP) GENOTYPING (JK), GENE ANALYSIS, SLC14A1 (SOLUTE CARRIER FAMILY 14 MEMBER 1 [KIDD BLOOD GROUP]) GENE PROMOTER, EXON 9
0193U RED CELL ANTIGEN (JR BLOOD GROUP) GENOTYPING (JR), GENE ANALYSIS, ABCG2 (ATP BINDING CASSETTE SUBFAMILY G MEMBER 2 [JUNIOR BLOOD GROUP]) EXONS 2-26
0194U RED CELL ANTIGEN (KELL BLOOD GROUP) GENOTYPING (KEL), GENE ANALYSIS, KEL (KELL METALLO-ENDOPEPTIDASE [KELL BLOOD GROUP]) EXON 8
0195U KLF1 (KRUPPEL-LIKE FACTOR 1), TARGETED SEQUENCING (IE, EXON 13)
0196U RED CELL ANTIGEN (LUTHERAN BLOOD GROUP) GENOTYPING (LU), GENE ANALYSIS, BCAM (BASAL CELL ADHESION MOLECULE [LUTHERAN BLOOD GROUP]) EXON 3
0197U RED CELL ANTIGEN (LANDSTEINER-WIENER BLOOD GROUP) GENOTYPING (LW), GENE ANALYSIS, ICAM4 (INTERCELLULAR ADHESION MOLECULE 4 [LANDSTEINER-WIENER BLOOD GROUP]) EXON 1
0198U RED CELL ANTIGEN (RH BLOOD GROUP) GENOTYPING (RHD AND RHCE), GENE ANALYSIS SANGER/CHAIN TERMINATION/CONVENTIONAL SEQUENCING, RHD (RH BLOOD GROUP D ANTIGEN) EXONS 1-10 AND RHCE (RH BLOOD GROUP CCEE ANTIGENS) EXON 5
0199U RED CELL ANTIGEN (SCIANNA BLOOD GROUP) GENOTYPING (SC), GENE ANALYSIS, ERMAP (ERYTHROBLAST MEMBRANE ASSOCIATED PROTEIN [SCIANNA BLOOD GROUP]) EXONS 4, 12
0200U RED CELL ANTIGEN (KX BLOOD GROUP) GENOTYPING (XK), GENE ANALYSIS, XK (X-LINKED KX BLOOD GROUP) EXONS 1-3
0201U RED CELL ANTIGEN (YT BLOOD GROUP) GENOTYPING (YT), GENE ANALYSIS, ACHE (ACETYLCHOLINESTERASE [CARTWRIGHT BLOOD GROUP]) EXON 2
0221U RED CELL ANTIGEN (ABO BLOOD GROUP) GENOTYPING (ABO), GENE ANALYSIS, NEXT-GENERATION SEQUENCING, ABO (ABO, ALPHA 1-3-N-ACETYLGALACTOSAMINYLTRANSFERASE AND ALPHA 1-3-GALACTOSYLTRANSFERASE) GENE
0222U RED CELL ANTIGEN (RH BLOOD GROUP) GENOTYPING (RHD AND RHCE), GENE ANALYSIS, NEXT-GENERATION SEQUENCING, RH PROXIMAL PROMOTER, EXONS 1-10, PORTIONS OF INTRONS 2-3
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(115 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
C85.80 Other specified types of non-Hodgkin lymphoma, unspecified site
C85.89 Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites
C85.90 Non-Hodgkin lymphoma, unspecified, unspecified site
C85.91 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
C85.92 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes
C85.93 Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
C85.94 Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb
C85.95 Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb
C85.96 Non-Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
C85.97 Non-Hodgkin lymphoma, unspecified, spleen
C85.98 Non-Hodgkin lymphoma, unspecified, lymph nodes of multiple sites
C85.99 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C92.60 Acute myeloid leukemia with 11q23-abnormality not having achieved remission
C92.61 Acute myeloid leukemia with 11q23-abnormality in remission
C92.62 Acute myeloid leukemia with 11q23-abnormality in relapse
C92.A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission
C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission
C92.A2 Acute myeloid leukemia with multilineage dysplasia, in relapse
D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.Z Other myelodysplastic syndromes
D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency
D53.9 Nutritional anemia, unspecified
D55.0 Anemia due to glucose-6-phosphate dehydrogenase [G6PD] deficiency
D55.1 Anemia due to other disorders of glutathione metabolism
D55.29 Anemia due to other disorders of glycolytic enzymes
D55.3 Anemia due to disorders of nucleotide metabolism
D55.8 Other anemias due to enzyme disorders
D55.9 Anemia due to enzyme disorder, unspecified
D56.0 Alpha thalassemia
D56.1 Beta thalassemia
D56.2 Delta-beta thalassemia
D56.3 Thalassemia minor
D56.5 Hemoglobin E-beta thalassemia
D56.8 Other thalassemias
D56.9 Thalassemia, unspecified
D57.00 Hb-SS disease with crisis, unspecified
D57.01 Hb-SS disease with acute chest syndrome
D57.02 Hb-SS disease with splenic sequestration
D57.03 Hb-SS disease with cerebral vascular involvement
D57.04 Hb-SS disease with dactylitis
D57.09 Hb-SS disease with crisis with other specified complication
D57.1 Sickle-cell disease without crisis
D57.20 Sickle-cell/Hb-C disease without crisis
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.212 Sickle-cell/Hb-C disease with splenic sequestration
D57.213 Sickle-cell/Hb-C disease with cerebral vascular involvement
D57.214 Sickle-cell/Hb-C disease with dactylitis
D57.218 Sickle-cell/Hb-C disease with crisis with other specified complication
D57.219 Sickle-cell/Hb-C disease with crisis, unspecified
D57.3 Sickle-cell trait
D57.40 Sickle-cell thalassemia without crisis
D57.411 Sickle-cell thalassemia, unspecified, with acute chest syndrome
D57.412 Sickle-cell thalassemia, unspecified, with splenic sequestration
D57.413 Sickle-cell thalassemia, unspecified, with cerebral vascular involvement
D57.414 Sickle-cell thalassemia, unspecified, with dactylitis
D57.418 Sickle-cell thalassemia, unspecified, with crisis with other specified complication
D57.419 Sickle-cell thalassemia, unspecified, with crisis
D57.42 Sickle-cell thalassemia beta zero without crisis
D57.431 Sickle-cell thalassemia beta zero with acute chest syndrome
D57.432 Sickle-cell thalassemia beta zero with splenic sequestration
D57.433 Sickle-cell thalassemia beta zero with cerebral vascular involvement
D57.434 Sickle-cell thalassemia beta zero with dactylitis
D57.438 Sickle-cell thalassemia beta zero with crisis with other specified complication
D57.439 Sickle-cell thalassemia beta zero with crisis, unspecified
D57.44 Sickle-cell thalassemia beta plus without crisis
D57.451 Sickle-cell thalassemia beta plus with acute chest syndrome
D57.452 Sickle-cell thalassemia beta plus with splenic sequestration
D57.453 Sickle-cell thalassemia beta plus with cerebral vascular involvement
D57.454 Sickle-cell thalassemia beta plus with dactylitis
D57.458 Sickle-cell thalassemia beta plus with crisis with other specified complication
D57.459 Sickle-cell thalassemia beta plus with crisis, unspecified
D57.80 Other sickle-cell disorders without crisis
D57.811 Other sickle-cell disorders with acute chest syndrome
D57.812 Other sickle-cell disorders with splenic sequestration
D57.813 Other sickle-cell disorders with cerebral vascular involvement
D57.814 Other sickle-cell disorders with dactylitis
D57.818 Other sickle-cell disorders with crisis with other specified complication
D57.819 Other sickle-cell disorders with crisis, unspecified
D58.0 Hereditary spherocytosis
D58.1 Hereditary elliptocytosis
D58.9 Hereditary hemolytic anemia, unspecified
D59.0 Drug-induced autoimmune hemolytic anemia
D59.10 Autoimmune hemolytic anemia, unspecified
D59.11 Warm autoimmune hemolytic anemia
D59.12 Cold autoimmune hemolytic anemia
D59.13 Mixed type autoimmune hemolytic anemia
D59.19 Other autoimmune hemolytic anemia
D59.9 Acquired hemolytic anemia, unspecified
D60.0 Chronic acquired pure red cell aplasia
D60.1 Transient acquired pure red cell aplasia
D60.8 Other acquired pure red cell aplasias
D60.9 Acquired pure red cell aplasia, unspecified
D61.01 Constitutional (pure) red blood cell aplasia
D61.02 Shwachman-Diamond syndrome
D61.09 Other constitutional aplastic anemia
D61.1 Drug-induced aplastic anemia
D61.2 Aplastic anemia due to other external agents
D61.3 Idiopathic aplastic anemia
D61.89 Other specified aplastic anemias and other bone marrow failure syndromes
D63.0 Anemia in neoplastic disease
D63.1 Anemia in chronic kidney disease
D63.8 Anemia in other chronic diseases classified elsewhere
D64.0 Hereditary sideroblastic anemia
D64.1 Secondary sideroblastic anemia due to disease
D64.2 Secondary sideroblastic anemia due to drugs and toxins
D64.3 Other sideroblastic anemias
D64.4 Congenital dyserythropoietic anemia
D64.89 Other specified anemias
Z85.72 Personal history of non-Hodgkin lymphomas
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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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.

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Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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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
10/01/2023 R2

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added D57.04, D57.214, D57.414, D57.434, D57.454, D57.814, and D61.02. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/2023.

Under Article Text revised 1ST bullet to read “Select the appropriate CPT® or PLA code”. Revised 3rd and 6th bullets to remove “DEX Z-Code™” and “CPT”. Replaced with “DEX Z-Code®” and “CPT®”. This revision is effective on 10/1/2023.

Under CPT/HCPCS Codes Group 2: Codes the description was revised for 0180U, 0193U, 0200U, and 0221U. This revision is due to the 2022 Annual CPT/HCPCS Code Update and is effective on January 1, 2022.

12/06/2020 R1

Under CPT/HCPCS Codes Group 2: Codes added 0221U and 0222U. This revision is due to the Q4 CPT®/HCPCS Code Update.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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
11/22/2023 10/01/2023 - N/A Currently in Effect View
09/28/2023 10/01/2023 - N/A Superseded View
09/01/2023 10/01/2023 - N/A Superseded You are here
11/10/2020 12/06/2020 - 09/30/2023 Superseded View
10/14/2020 12/06/2020 - N/A Superseded View

Keywords

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