Please note that CPT® codes 81265 and 81266 describe services performed for recipient/donor testing and twin zygosity. Tests indicated for recipient/donor testing will be considered for payment and tests for twin zygosity will be denied as a statutorily excluded service. The following instructions outline the correct reporting of recipient/donor testing for transplant services.
Chimerism analysis to identify appropriate donors and monitor engraftment success or disease reoccurrence is a covered Medicare service.
- Code 81265 should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.
- Code 81266, when used in bone marrow transplants to report an additional double-cord blood sample, is a covered service.
- Code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, an additional 81265 should NOT be submitted in addition to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.
Code 81267 should be reported for the findings of the pre and post-transplant comparison.
- Code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.
MolDX would not expect to see a claim for 81265 pre-transplant and an additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant and an additional claim for 81268.
EXCEPTIONS: Although the initial chimerism testing, code 81265, for engraftment is usually limited to once in a lifetime, MolDX recognizes special circumstances may require an additional service and will consider approval on a case-by-case basis through the appeal process.
To report a Molecular Diagnostic Test service, please submit the following claim information:
- Select appropriate CPT® code
- Enter 1 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