Local Coverage Article Billing and Coding

Billing and Coding: Pharmacogenomics Testing

A58801

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General Information

Article ID
A58801
Article Title
Billing and Coding: Pharmacogenomics Testing
Article Type
Billing and Coding
Original Effective Date
12/12/2021
Revision Effective Date
01/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 2, Section 90.1 Pharmacogenomic Testing to Predict Warfarin Responsiveness
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 1, Section 60 Provider Billing of Non-covered Charges on Institutional Claims
    • Chapter 16 Laboratory Services
    • Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI), Section 20.9.1.1 Instructions for Codes With Modifiers (A/B MACs (B) Only) and Section 40 Clinical Diagnostic Laboratory Fee Schedule

National Correct Coding Initiative (NCCI) Citation:

  • NCCI Policy Manual for Medicare Services,
    • Chapter 10 Pathology/Laboratory Services, (A) Introduction and (F) Molecular Pathology

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.
  • Title XVIII of the Social Security Act, Section 1834A(d) This section addresses payment for new advanced diagnostic laboratory tests.

Code of Federal Register (CFR) References:

  • CFR, Title 42, Volume 3, Chapter IV, Part 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.
  • CFR, Title 42, Volume 3, Chapter IV, Part 414, Subpart G Payment for Clinical Diagnostic Laboratory Tests.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39063 Pharmacogenomics Testing. Please refer to the LCD for reasonable and necessary requirements.

Laboratory tests that investigate the same germline genetic content, for the same genetic information, that has already been tested in the same Medicare beneficiary is duplicative and should not be reported.

Examples of germline tests include (but are not limited to) single gene and specific gene panel tests for: hereditary cancer syndromes or cancer predisposition, inherited disorders, and pharmacogenomics/cytochrome P450 testing.

Providers should take reasonable measures to be aware of what, if any, germline testing a beneficiary has had prior to billing for germline testing so as to avoid billing Medicare for services that are not medically reasonable and necessary. Clinicians who order germline testing may wish to be aware of whether the test that they are ordering is covered under Medicare and may wish to verify that they are not ordering repeat germline testing.

Germline testing, including panels containing some genetic content already tested in the same Medicare beneficiary, may be considered medically reasonable and necessary if there is established clinical utility in the remaining, non-duplicative genetic components of the test.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

CPT codes 81355 (VKORC1) and 81227 (CYP2C9) are not considered medically reasonable and necessary for warfarin testing. Please refer to the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 90.1 Pharmacogenomic Testing to Predict Warfarin Responsiveness.

If a treating clinician orders a single gene test or a test for a particular allele(s), but as a matter of operational practicality, the laboratory tests that single gene or allele on a platform that looks for variants in other genes/alleles as well, that particular test done in that particular instance is considered a single gene/allele test for coverage purposes. In this scenario the provider may bill for the component of the test that was medically reasonable and necessary (in this example, the single gene test).

Genes can be assayed serially or in parallel. Genes assayed on the same date of service are considered to be assayed in parallel if the result of one assay does not affect the decision to complete the assay on another gene, and the two genes are being tested for the same indication. Genes assayed on the same date of service are considered to be assayed serially when there is a reflexive decision component where the results of the analysis of one or more genes determines whether the results of additional analyses are medically reasonable and necessary. If two or more genes are tested, please refer to the Molecular Pathology and Genetic Testing Article A58917 for multi-gene testing.

When billing Part B claims, the drug or drugs in consideration for use that require the use of the PHARMACOGENOMICS (PGx) test must be submitted in the applicable detail line 2400 loop.

The following 2 tables represent relevant gene/drug associations. Table 1 is from CPIC and Table 2 is from FDA sources.

Table 1. Current CPIC guidelines as of December 28, 2020:

Gene/Test

CPT Code

Intended use for Drug

Brand Name

CFTR

81220

ivacaftor

Kalydeco

CYP2B6

81479

efavirenz

Sustiva

CYP2C19

81225

clopidogrel, voriconazole

Plavix, Vfend

CYP2C19

81225

PPIs (class): omeprazole, lansoprazole, pantoprazole, dexlansoprazole

Prilosec, Prevacid, Protonix, Dexilant

CYP2C19

81225

SSRIs (class): citalopram, escitalopram, fluvoxamine, paroxetine, sertraline

Celexa, Lexapro, Luvox, Paxil, Zoloft

CYP2C19

81225

Tricyclic antidepressants (class): amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine

Anafranil, Norpramin, Silenor,
Pamelor, Surmontil

CYP2C9

81227

phenytoin

Dilantin

CYP2C9

81227

warfarin

Jantoven, Coumadin

CYP2C9

81227

NSAIDs (class): aspirin, diclofenac, celecoxib, flurbiprofen, aceclofenac, ibuprofen, indomethacin, lornoxicam, lumiracoxib, meloxicam, metamizole, nabumetone, naproxen, piroxicam, tenoxicam

Voltaren, Celebrex, Ocufen, Tivorbex, Chlortenoxicam, Mobic, Dipyrone, Relafen, Feldene, Mobiflex

HLA-B

81381, 81374

abacavir, allopurinol, oxcarbazepine, phenytoin, carbamazepine

Ziagen, Zyloprim, Aloprim, Trileptal, Oxtellar, Dilantin, Tegretol

CYP4F2

81479

warfarin

Jantoven, Coumadin

VKORC1

81355

warfarin

Jantoven, Coumadin

CYP2D6

81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

atomoxetine, codeine, ondansetron, tropisetron, tamoxifen

Strattera, Zofran, Soltamox

CYP2D6

81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

SSRIs (class): citalopram, escitalopram, fluvoxamine, paroxetine, sertraline

Celexa, Lexapro, Luvox, Paxil, Zoloft

CYP2D6

81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

Tricyclic antidepressants (class): amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine

Anafranil, Norpramin, Silenor,
Pamelor, Surmontil

CYP3A5

81231

tacrolimus

Prograf, Protopic

DPYD

81232

Fluoropyrimidines (class): fluorouracil, capecitabine, tegafur

Adrucil, Xeloda

G6PD

81247

rasburicase

Elitek

HLA-A

81381, 81374

carbamazepine

Tegretol

IFNL3

81283

ribavirin, peginterferon alfa-2a, peginterferon alfa-2b

Copegus, Pegasys, Pegintron, Sylatron

RYR1

81406

Volatile anesthetics (class): desflurane, enflurane, halothane, isoflurane, methoxyflurane, sevoflurane, succinylcholine

Suprane, Ethrane, Fluothane, Forane, Penthrox, Ultane, Anectine, Quelicin

CACNA1S

81479

Volatile anesthetics (class): desflurane, enflurane, halothane, isoflurane, methoxyflurane, sevoflurane, succinylcholine

Suprane, Ethrane, Fluothane, Forane, Penthrox, Ultane, Anectine, Quelicin

SLCO1B1

81328

simvastatin

Zocor, FloLipid

NUDT15

81306, 0286U

Thiopurines (class): mercaptopurine, azathioprine, thioguanine

Purixan, Azasan, Tabloid

TPMT

81335

Thiopurines (class): mercaptopurine, azathioprine, thioguanine

Purixan, Azasan, Tabloid

UGT1A1

81350

atazanavir

Reyataz


Table 2.
Table of PHARMACOGENOMIC associations from the FDA for which the data support therapeutic recommendations or a potential impact on safety or response (last updated February 2020):

Gene

CPT Code

Drug

Brand Name

Affected Subgroups+

BCHE

81479

mivacurium

Mivacurium chloride

intermediate or poor metabolizers

BCHE

81479

succinylcholine

Anectine

intermediate or poor metabolizers

CYP2B6

81479

efavirenz

Sustiva

poor metabolizers

CYP2C19

81225

brivaracetam

Briviact

intermediate or poor metabolizers

CYP2C19

81225

citalopram

Celexa

poor metabolizers

CYP2C19

81225

clobazam

Onfi

intermediate or poor metabolizers

CYP2C19

81225

clopidogrel

Plavix

intermediate or poor metabolizers

CYP2C19

81225

flibanserin

Addyi

poor metabolizers

CYP2C19

81225

pantoprazole

Protonix

poor metabolizers

CYP2C9

81227

celecoxib

Celebrex

poor metabolizers

CYP2C9

81227

dronabinol

Marinol

intermediate or poor metabolizers

CYP2C9

81227

erdafitinib

Balversa

*3/*3 (poor metabolizers)

CYP2C9

81227

flurbiprofen

Ansaid

poor metabolizers

CYP2C9

81227

piroxicam

Feldene

intermediate or poor metabolizers

CYP2C9

81227

siponimod

Mayzent

intermediate or poor metabolizers

CYP2C9

81227

warfarin

Coumadin

intermediate or poor metabolizers

CYP2D6

81226

amphetamine

Adderall

poor metabolizers

CYP2D6

81226

aripiprazole

Abilify

poor metabolizers

CYP2D6

81226

aripiprazole lauroxil

Aristada

poor metabolizers

CYP2D6

81226

atomoxetine

Strattera

poor metabolizers

CYP2D6

81226

brexpiprazole

Rexulti

poor metabolizers

CYP2D6

81226

clozapine

Clozaril, FazaClo, Versacloz

poor metabolizers

CYP2D6

81226

codeine

ultrarapid metabolizers, poor metabolizers

CYP2D6

81226

deutetrabenazine

Austedo

poor metabolizers

CYP2D6

81226

eliglustat

Cerdelga

ultrarapid, normal, intermediate, or poor metabolizers

CYP2D6

81226

gefitinib

Iressa

poor metabolizers

CYP2D6

81226

Iloperidone

Fanapt

poor metabolizers

CYP2D6

81226

lofexidine

Lucemyra

poor metabolizers

CYP2D6

81226

meclizine

Antivert

ultrarapid, intermediate, or poor metabolizers

CYP2D6

81226

metoclopramide

Reglan

poor metabolizers

CYP2D6

81226

pimozide

Orap

poor metabolizers

CYP2D6

81226

propafenone

Rythmol

poor metabolizers

CYP2D6

81226

tetrabenazine

Xenazine

poor metabolizers

CYP2D6

81226

thioridazine

Mellaril

poor metabolizers

CYP2D6

81226

tramadol

Ultram

ultrarapid metabolizers

CYP2D6

81226

valbenazine

Ingrezza

poor metabolizers

CYP2D6

81226

venlafaxine

Effexor

poor metabolizers

CYP2D6

81226

vortioxetine

Trintellix

poor metabolizers

CYP2D6

81226

carvedilol

Coreg

poor metabolizers

CYP2D6

81226

cevimeline

Evoxac

poor metabolizers

CYP2D6

81226

perphenazine

Trilafon

poor metabolizers

CYP2D6

81226

tolterodine

Detrol

poor metabolizers

CYP3A5

81231

tacrolimus

Prograf

intermediate or normal metabolizers

CYP4F2

81479

warfarin

Coumadin

V433M variant carriers

DPYD

81232

capecitabine

Xeloda

intermediate or poor metabolizers

DPYD

81232

fluorouracil

Fluoroplex, Tolak, Efudex

intermediate or poor metabolizer

HLA-A

81381, 81374

carbamazepine

Tegretol

*31:01 allele positive

HLA-B

81381, 81374

abacavir

Ziagen

*57:01 allele positive

HLA-B

81381, 81374

carbamazepine

Tegretol

*15:02 allele positive

HLA-B

81381, 81374

allopurinol

Zyloprim, Aloprim

*58:01 allele positive

HLA-B

81381, 81374

oxcarbazepine

Trileptal, Oxtellar

*15:02 allele positive

HLA-B

81381, 81374

pazopanib

Votrient

*57:01 allele positive

HLA-DQA1

81383, 81377

lapatinib

Tykerb

*02:01 allele positive

HLA-DRB1

81383, 81377

lapatinib

Tykerb

*07:01 allele positive

NAT2

81479

amifampridine

Firdapse, Ruzurgi

poor metabolizers

NAT2

81479

amifampridine phosphate

poor metabolizers

Nonspecific (NAT)

81479

isoniazid

poor metabolizers

Nonspecific (NAT)

81479

procainamide

Pronestyl, Procan

poor metabolizers

Nonspecific (NAT)

81479

sulfamethoxazole and trimethoprim

Sulfatrim, Bactrim

poor metabolizers

Nonspecific (NAT)

81479

sulfasalazine

Azulfidine

poor metabolizers

SLCO1B1

81328

simvastatin

FloLipid, Zocor

521 TC or 521 CC (intermediate or poor function transporters)

NUDT15 and/or

TPMT

81306, 81335, 0286U

azathioprine

Imuran, Azasan

intermediate or poor metabolizers

NUDT15 and/or

TPMT

81306, 81335, 0286U

mercaptopurine

Purixan, Purinethol

intermediate or poor metabolizers

NUDT15 and/or

TPMT

81306, 81335, 0286U

thioguanine

Tabloid

intermediate or poor metabolizers

UGT1A1

81350

belinostat

Beleodaq

*28/*28 (poor metabolizers)

UGT1A1

81350

irinotecan

Camptosar

*28/*28 (poor metabolizers)

UGT1A1

81350

nilotinib

Tasigna

*28/*28 (poor metabolizers)

UGT1A1

81350

pazopanib

Votrient

*28/*28 (poor metabolizers)

VKORC1

81355

warfarin

Coumadin

-1639G>A variant carriers


The CPT codes relevant to the related LCD are listed in the coding section below. If no CPT code is available for the gene(s) being tested, the unlisted molecular pathology procedure code 81479 should be used as indicated below.

Utilization Parameters

Germline testing may be performed once in a lifetime per beneficiary.

Documentation Requirements

    1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
    2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
    3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
    4. The provider performing the service must have a record of what drug(s) is/are being considered and for what indication to ensure the test performed is medically reasonable and necessary.
    5. The clinical record must clearly show the use of or intent to prescribe a drug that has known drug-gene interactions that require a PGx test to be ordered to define the safe use of that drug in that patient.


Coding Information

When more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will deny every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. Billing the 59 modifier may result in a request for medical records.

The molecular pathology codes include all analytical services performed during the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection).

 

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
81220 Cftr gene com variants

Group 2

(1 Code)
Group 2 Paragraph

N/A

Group 2 Codes
CodeDescription
81225 Cyp2c19 gene com variants

Group 3

(8 Codes)
Group 3 Paragraph

N/A

Group 3 Codes
CodeDescription
81226 Cyp2d6 gene com variants
0070U Cyp2d6 gen com&slct rar vrnt
0071U Cyp2d6 full gene sequence
0072U Cyp2d6 gen cyp2d6-2d7 hybrid
0073U Cyp2d6 gen cyp2d7-2d6 hybrid
0074U Cyp2d6 nonduplicated gene
0075U Cyp2d6 5' gene dup/mlt
0076U Cyp2d6 3' gene dup/mlt

Group 4

(1 Code)
Group 4 Paragraph

N/A

Group 4 Codes
CodeDescription
81226 Cyp2d6 gene com variants

Group 5

(1 Code)
Group 5 Paragraph

N/A

Group 5 Codes
CodeDescription
81227 Cyp2c9 gene com variants

Group 6

(1 Code)
Group 6 Paragraph

N/A

Group 6 Codes
CodeDescription
81231 Cyp3a5 gene common variants

Group 7

(1 Code)
Group 7 Paragraph

N/A

Group 7 Codes
CodeDescription
81232 Dpyd gene common variants

Group 8

(1 Code)
Group 8 Paragraph

N/A

Group 8 Codes
CodeDescription
81247 G6pd gene alys cmn variant

Group 9

(1 Code)
Group 9 Paragraph

N/A

Group 9 Codes
CodeDescription
81283 Ifnl3 gene

Group 10

(3 Codes)
Group 10 Paragraph

N/A

Group 10 Codes
CodeDescription
81306 Nudt15 gene common variants
81335 Tpmt gene com variants
0286U Cep72 nudt15&tpmt gene alys

Group 11

(1 Code)
Group 11 Paragraph

N/A

Group 11 Codes
CodeDescription
81328 Slco1b1 gene com variants

Group 12

(1 Code)
Group 12 Paragraph

N/A

Group 12 Codes
CodeDescription
81350 Ugt1a1 gene common variants

Group 13

(2 Codes)
Group 13 Paragraph

N/A

Group 13 Codes
CodeDescription
81374 Hla i typing 1 antigen lr
81381 Hla i typing 1 allele hr

Group 14

(2 Codes)
Group 14 Paragraph

N/A

Group 14 Codes
CodeDescription
81377 Hla ii type 1 ag equiv lr
81383 Hla ii typing 1 allele hr

Group 15

(1 Code)
Group 15 Paragraph

N/A

Group 15 Codes
CodeDescription
81406 Mopath procedure level 7

Group 16

(1 Code)
Group 16 Paragraph

Report code 81479 and gene test CYP2B6 in the claim narrative/remarks.

Group 16 Codes
CodeDescription
81479 Unlisted molecular pathology

Group 17

(1 Code)
Group 17 Paragraph

Report code 81479 and gene test CYP4F2 in the claim narrative/remarks.

 

Group 17 Codes
CodeDescription
81479 Unlisted molecular pathology

Group 18

(1 Code)
Group 18 Paragraph

Report code 81479 and gene test CACNA1S in the claim narrative/remarks.

Group 18 Codes
CodeDescription
81479 Unlisted molecular pathology

Group 19

(1 Code)
Group 19 Paragraph

Report code 81479 and gene test BCHE in the claim narrative/remarks.

Group 19 Codes
CodeDescription
81479 Unlisted molecular pathology

Group 20

(1 Code)
Group 20 Paragraph

Report code 81479 and gene test NAT2 in the claim narrative/remarks.

Group 20 Codes
CodeDescription
81479 Unlisted molecular pathology

Group 21

(1 Code)
Group 21 Paragraph

Report code 81479 and gene test Nonspecific (NAT) in the claim narrative/remarks.

Group 21 Codes
CodeDescription
81479 Unlisted molecular pathology

Group 22

(18 Codes)
Group 22 Paragraph

Consistent with the LCD, the following CPT codes are Non-Covered for pharmacogenomic testing:

Group 22 Codes
CodeDescription
81230 Cyp3a4 gene common variants
81346 Tyms gene com variants
81355 Vkorc1 gene
81407 Mopath procedure level 8
81408 Mopath procedure level 9
0029U Rx metab advrs trgt seq alys
0031U Cyp1a2 gene
0032U Comt gene
0033U Htr2a htr2c genes
0117U Pain mgmt 11 endogenous anal
0173U Psyc gen alys panel 14 genes
0175U Psyc gen alys panel 15 genes
0289U Neuro alzheimer mrna 24 gen
0290U Pain mgmt mrna gen xprsn 36
0291U Psyc mood do mrna 144 genes
0292U Psyc strs do mrna 72 genes
0293U Psyc suicidal idea mrna 54
0294U Lngvty&mrtlty rsk mrna 18gen

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT code: 81220.

Group 1 Codes
CodeDescription
E84.8 Cystic fibrosis with other manifestations

Group 2

(67 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81225.

Group 2 Codes
CodeDescription
B37.81 Candidal esophagitis
B37.89 Other sites of candidiasis
B44.0 Invasive pulmonary aspergillosis
E16.4 Increased secretion of gastrin
E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified
E31.8 Other polyglandular dysfunction
F32.1 Major depressive disorder, single episode, moderate
F32.2 Major depressive disorder, single episode, severe without psychotic features
F32.3 Major depressive disorder, single episode, severe with psychotic features
F32.4 Major depressive disorder, single episode, in partial remission
F32.9 Major depressive disorder, single episode, unspecified
F33.1 Major depressive disorder, recurrent, moderate
F33.2 Major depressive disorder, recurrent severe without psychotic features
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
F33.41 Major depressive disorder, recurrent, in partial remission
F33.9 Major depressive disorder, recurrent, unspecified
F40.01 Agoraphobia with panic disorder
F40.11 Social phobia, generalized
F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic
F52.0* Hypoactive sexual desire disorder
F60.5 Obsessive-compulsive personality disorder
G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus
G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus
G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus
G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G47.09 Other insomnia
I20.0 Unstable angina
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I21.A1 Myocardial infarction type 2
I21.A9 Other myocardial infarction type
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I25.2 Old myocardial infarction
I69.30 Unspecified sequelae of cerebral infarction
K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding
K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
K21.9 Gastro-esophageal reflux disease without esophagitis
K22.10 Ulcer of esophagus without bleeding
K22.11 Ulcer of esophagus with bleeding
K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation
K26.6 Chronic or unspecified duodenal ulcer with both hemorrhage and perforation
K26.7 Chronic duodenal ulcer without hemorrhage or perforation
K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation
N95.8* Other specified menopausal and perimenopausal disorders
Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z98.61 Coronary angioplasty status
Z98.62 Peripheral vascular angioplasty status
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: ICD-10 code N95.8 must be reported with ICD-10 code F52.0.

Group 3

(31 Codes)
Group 3 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, and 0076U.

Group 3 Codes
CodeDescription
C50.919* Malignant neoplasm of unspecified site of unspecified female breast
C50.929* Malignant neoplasm of unspecified site of unspecified male breast
F32.1 Major depressive disorder, single episode, moderate
F32.2 Major depressive disorder, single episode, severe without psychotic features
F32.3 Major depressive disorder, single episode, severe with psychotic features
F32.4 Major depressive disorder, single episode, in partial remission
F32.9 Major depressive disorder, single episode, unspecified
F33.1 Major depressive disorder, recurrent, moderate
F33.2 Major depressive disorder, recurrent severe without psychotic features
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
F33.41 Major depressive disorder, recurrent, in partial remission
F33.9 Major depressive disorder, recurrent, unspecified
F40.01 Agoraphobia with panic disorder
F40.11 Social phobia, generalized
F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic
F60.5 Obsessive-compulsive personality disorder
F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2 Attention-deficit hyperactivity disorder, combined type
F90.8 Attention-deficit hyperactivity disorder, other type
G47.09 Other insomnia
G89.11 Acute pain due to trauma
G89.18 Other acute postprocedural pain
G89.29 Other chronic pain
R11.2* Nausea with vomiting, unspecified
R52 Pain, unspecified
Z48.89* Encounter for other specified surgical aftercare
Z51.0* Encounter for antineoplastic radiation therapy
Z92.21* Personal history of antineoplastic chemotherapy
Group 3 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code C50.919 or C50.929 with ICD-10 code Z17.0 or Z17.1 to identify estrogen receptor status.

*Dual diagnosis requirement: ICD-10 code R11.2 must be reported with ICD-10 code Z48.89, Z51.0 or Z92.21.

Group 4

(73 Codes)
Group 4 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81226

Group 4 Codes
CodeDescription
C34.90* Malignant neoplasm of unspecified part of unspecified bronchus or lung
E75.22 Gaucher disease
F11.23 Opioid dependence with withdrawal
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.5 Residual schizophrenia
F20.81 Schizophreniform disorder
F20.89 Other schizophrenia
F31.0 Bipolar disorder, current episode hypomanic
F31.11 Bipolar disorder, current episode manic without psychotic features, mild
F31.12 Bipolar disorder, current episode manic without psychotic features, moderate
F31.13 Bipolar disorder, current episode manic without psychotic features, severe
F31.2 Bipolar disorder, current episode manic severe with psychotic features
F31.31 Bipolar disorder, current episode depressed, mild
F31.32 Bipolar disorder, current episode depressed, moderate
F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features
F31.61 Bipolar disorder, current episode mixed, mild
F31.62 Bipolar disorder, current episode mixed, moderate
F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features
F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features
F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic
F31.73 Bipolar disorder, in partial remission, most recent episode manic
F31.75 Bipolar disorder, in partial remission, most recent episode depressed
F31.77 Bipolar disorder, in partial remission, most recent episode mixed
F32.1 Major depressive disorder, single episode, moderate
F32.2 Major depressive disorder, single episode, severe without psychotic features
F32.3 Major depressive disorder, single episode, severe with psychotic features
F32.4 Major depressive disorder, single episode, in partial remission
F32.9 Major depressive disorder, single episode, unspecified
F33.1 Major depressive disorder, recurrent, moderate
F33.2 Major depressive disorder, recurrent severe without psychotic features
F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
F33.41 Major depressive disorder, recurrent, in partial remission
F33.9 Major depressive disorder, recurrent, unspecified
F84.0 Autistic disorder
F90.1 Attention-deficit hyperactivity disorder, predominantly hyperactive type
F90.2 Attention-deficit hyperactivity disorder, combined type
F90.8 Attention-deficit hyperactivity disorder, other type
F95.2 Tourette's disorder
G10 Huntington's disease
G24.01 Drug induced subacute dyskinesia
G47.411 Narcolepsy with cataplexy
G47.419 Narcolepsy without cataplexy
G89.11 Acute pain due to trauma
G89.18 Other acute postprocedural pain
G89.29 Other chronic pain
I10 Essential (primary) hypertension
I48.0 Paroxysmal atrial fibrillation
I48.11 Longstanding persistent atrial fibrillation
I48.19 Other persistent atrial fibrillation
I50.1 Left ventricular failure, unspecified
I50.20 Unspecified systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.89 Other heart failure
I50.9 Heart failure, unspecified
K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding
K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
K21.9 Gastro-esophageal reflux disease without esophagitis
K31.84* Gastroparesis
M35.00 Sjogren syndrome, unspecified
N39.41* Urge incontinence
N39.46* Mixed incontinence
R11.2 Nausea with vomiting, unspecified
R45.851* Suicidal ideations
R52 Pain, unspecified
T75.3XXA Motion sickness, initial encounter
T75.3XXD Motion sickness, subsequent encounter
T75.3XXS Motion sickness, sequela
Z92.21* Personal history of antineoplastic chemotherapy
Group 4 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: ICD-10 code C34.90 must be reported with ICD-10 code Z92.21 to identify personal history of antineoplastic chemotherapy.

*Report ICD-10 code K31.84 with a code for diabetes mellitus (E08.43, E09.43, E10.43, E11.43, or E13.43).

*When reporting ICD-10 codes N39.41 or N39.46, also report ICD-10 code N32.81 for any associated overactive bladder.

*Dual diagnosis requirement: ICD-10 code R45.851 must be reported with one of the following ICD-10 codes to identify schizophrenia: F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, or F20.89 (these ICD-10 codes for schizophrenia may also be reported as stand-alone codes).

Group 5

(13 Codes)
Group 5 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81227.

Group 5 Codes
CodeDescription
G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
Z48.811 Encounter for surgical aftercare following surgery on the nervous system

Group 6

(3 Codes)
Group 6 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81231.

Group 6 Codes
CodeDescription
Z94.0 Kidney transplant status
Z94.1 Heart transplant status
Z94.4 Liver transplant status

Group 7

(7 Codes)
Group 7 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81232.

Group 7 Codes
CodeDescription
C16.9 Malignant neoplasm of stomach, unspecified
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C25.9 Malignant neoplasm of pancreas, unspecified
C50.919* Malignant neoplasm of unspecified site of unspecified female breast
C50.929* Malignant neoplasm of unspecified site of unspecified male breast
Group 7 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code C50.919 or C50.929 with ICD-10 code Z17.0 or Z17.1 to identify estrogen receptor status.

Group 8

(1 Code)
Group 8 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT code: 81247

Group 8 Codes
CodeDescription
E79.9* Disorder of purine and pyrimidine metabolism, unspecified
Group 8 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code E79.9 with ICD-10 code to identify leukemia, lymphoma, or solid tumor malignancy (C80.1, C95.90, C95.91, C95.92, C96.Z, C96.9, Z85.6, Z85.79, or Z85.9, as applicable) AND an ICD-10 code to identify anti-cancer therapy used (Z92.21, Z92.25, Z92.29, or Z92.3, as applicable).

Group 9

(4 Codes)
Group 9 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81283.

Group 9 Codes
CodeDescription
C43.9* Malignant melanoma of skin, unspecified
C77.9* Secondary and unspecified malignant neoplasm of lymph node, unspecified
K73.9* Chronic hepatitis, unspecified
K76.9* Liver disease, unspecified
Group 9 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: ICD-10 code C43.9 must be reported with ICD-10 code C77.9 to indicate nodal involvement.

*Dual diagnosis requirement: ICD-10 code K73.9 must be reported with ICD-10 code K76.9 to indicate compensated liver disease (and report ICD-10 code B20, as applicable).

Group 10

(9 Codes)
Group 10 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 81306, 81335, and 0286U.

Group 10 Codes
CodeDescription
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C92.00 Acute myeloblastic leukemia, not having achieved remission
C92.01 Acute myeloblastic leukemia, in remission
C92.02 Acute myeloblastic leukemia, in relapse
M06.89 Other specified rheumatoid arthritis, multiple sites
M06.8A Other specified rheumatoid arthritis, other specified site
Z94.0 Kidney transplant status

Group 11

(8 Codes)
Group 11 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81328.

Group 11 Codes
CodeDescription
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
E78.49 Other hyperlipidemia
Z86.39 Personal history of other endocrine, nutritional and metabolic disease
Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z86.79 Personal history of other diseases of the circulatory system

Group 12

(14 Codes)
Group 12 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81350.

Group 12 Codes
CodeDescription
B20 Human immunodeficiency virus [HIV] disease
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C49.9* Malignant neoplasm of connective and soft tissue, unspecified
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C84.40 Peripheral T-cell lymphoma, not classified, unspecified site
C84.48 Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.12 Chronic myeloid leukemia, BCR/ABL-positive, in relapse
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z85.030 Personal history of malignant carcinoid tumor of large intestine
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.040 Personal history of malignant carcinoid tumor of rectum
Group 12 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code C49.9 with ICD-10 code Z92.21 to indicate prior chemotherapy.

Group 13

(46 Codes)
Group 13 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 81374 and 81381.

Group 13 Codes
CodeDescription
B20 Human immunodeficiency virus [HIV] disease
C49.9* Malignant neoplasm of connective and soft tissue, unspecified
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus
G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus
G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus
G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus
G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus
G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus
G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.801 Other epilepsy, not intractable, with status epilepticus
G40.802 Other epilepsy, not intractable, without status epilepticus
G40.803 Other epilepsy, intractable, with status epilepticus
G40.804 Other epilepsy, intractable, without status epilepticus
G50.0 Trigeminal neuralgia
M1A.00X0 Idiopathic chronic gout, unspecified site, without tophus (tophi)
M1A.00X1 Idiopathic chronic gout, unspecified site, with tophus (tophi)
M1A.09X0 Idiopathic chronic gout, multiple sites, without tophus (tophi)
M1A.09X1 Idiopathic chronic gout, multiple sites, with tophus (tophi)
M1A.40X0 Other secondary chronic gout, unspecified site, without tophus (tophi)
M1A.40X1 Other secondary chronic gout, unspecified site, with tophus (tophi)
M1A.49X0 Other secondary chronic gout, multiple sites, without tophus (tophi)
M1A.49X1 Other secondary chronic gout, multiple sites, with tophus (tophi)
M1A.9XX0 Chronic gout, unspecified, without tophus (tophi)
M1A.9XX1 Chronic gout, unspecified, with tophus (tophi)
M10.00 Idiopathic gout, unspecified site
M10.09 Idiopathic gout, multiple sites
M10.40 Other secondary gout, unspecified site
M10.49 Other secondary gout, multiple sites
M10.9 Gout, unspecified
N20.9 Urinary calculus, unspecified
Z48.811 Encounter for surgical aftercare following surgery on the nervous system
Z85.6 Personal history of leukemia
Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues
Z85.9 Personal history of malignant neoplasm, unspecified
Z92.25 Personal history of immunosuppression therapy
Z92.3 Personal history of irradiation
Group 13 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code C49.9 with ICD-10 code Z92.21 to indicate prior chemotherapy.

Group 14

(2 Codes)
Group 14 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 81377 and 81383.

Group 14 Codes
CodeDescription
C50.919* Malignant neoplasm of unspecified site of unspecified female breast
C50.929* Malignant neoplasm of unspecified site of unspecified male breast
Group 14 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code C50.919 or C50.929 with ICD-10 codes Z15.01 and Z92.21 and/or Z92.22 OR

*Report ICD-10 code C50.919 with ICD-10 codes Z15.01, Z17.0, and Z79.890.

Group 15

(12 Codes)
Group 15 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81406.

Group 15 Codes
CodeDescription
T41.0X5A Adverse effect of inhaled anesthetics, initial encounter
T41.0X5D Adverse effect of inhaled anesthetics, subsequent encounter
T41.0X5S Adverse effect of inhaled anesthetics, sequela
T41.0X6A Underdosing of inhaled anesthetics, initial encounter
T41.0X6D Underdosing of inhaled anesthetics, subsequent encounter
T41.0X6S Underdosing of inhaled anesthetics, sequela
T41.1X5A Adverse effect of intravenous anesthetics, initial encounter
T41.1X5D Adverse effect of intravenous anesthetics, subsequent encounter
T41.1X5S Adverse effect of intravenous anesthetics, sequela
T41.1X6A Underdosing of intravenous anesthetics, initial encounter
T41.1X6D Underdosing of intravenous anesthetics, subsequent encounter
T41.1X6S Underdosing of intravenous anesthetics, sequela

Group 16

(1 Code)
Group 16 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT code: 81479 and Gene Test CYP2B6.

Group 16 Codes
CodeDescription
B20 Human immunodeficiency virus [HIV] disease

Group 17

(36 Codes)
Group 17 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81479 and Gene Test CYP4F2.

Group 17 Codes
CodeDescription
I21.9 Acute myocardial infarction, unspecified
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
I25.2 Old myocardial infarction
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale
I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I48.11 Longstanding persistent atrial fibrillation
I48.19 Other persistent atrial fibrillation
I48.20 Chronic atrial fibrillation, unspecified
I48.21 Permanent atrial fibrillation
I51.3 Intracardiac thrombosis, not elsewhere classified
I82.890 Acute embolism and thrombosis of other specified veins
I82.891 Chronic embolism and thrombosis of other specified veins
T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.817D Embolism due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.817S Embolism due to cardiac prosthetic devices, implants and grafts, sequela
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.818D Embolism due to vascular prosthetic devices, implants and grafts, subsequent encounter
T82.818S Embolism due to vascular prosthetic devices, implants and grafts, sequela
T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.867D Thrombosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter
T82.867S Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.868D Thrombosis due to vascular prosthetic devices, implants and grafts, subsequent encounter
T82.868S Thrombosis due to vascular prosthetic devices, implants and grafts, sequela
Z79.01 Long term (current) use of anticoagulants
Z79.02 Long term (current) use of antithrombotics/antiplatelets
Z86.711 Personal history of pulmonary embolism
Z86.718 Personal history of other venous thrombosis and embolism
Z86.79 Personal history of other diseases of the circulatory system
Z95.2 Presence of prosthetic heart valve
Z95.4 Presence of other heart-valve replacement

Group 18

(12 Codes)
Group 18 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81479 and Gene Test CACNA1S.

Group 18 Codes
CodeDescription
T41.0X5A Adverse effect of inhaled anesthetics, initial encounter
T41.0X5D Adverse effect of inhaled anesthetics, subsequent encounter
T41.0X5S Adverse effect of inhaled anesthetics, sequela
T41.0X6A Underdosing of inhaled anesthetics, initial encounter
T41.0X6D Underdosing of inhaled anesthetics, subsequent encounter
T41.0X6S Underdosing of inhaled anesthetics, sequela
T41.1X5A Adverse effect of intravenous anesthetics, initial encounter
T41.1X5D Adverse effect of intravenous anesthetics, subsequent encounter
T41.1X5S Adverse effect of intravenous anesthetics, sequela
T41.1X6A Underdosing of intravenous anesthetics, initial encounter
T41.1X6D Underdosing of intravenous anesthetics, subsequent encounter
T41.1X6S Underdosing of intravenous anesthetics, sequela

Group 19

(6 Codes)
Group 19 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81479 and Gene Test BCHE.

Group 19 Codes
CodeDescription
T41.1X5A Adverse effect of intravenous anesthetics, initial encounter
T41.1X5D Adverse effect of intravenous anesthetics, subsequent encounter
T41.1X5S Adverse effect of intravenous anesthetics, sequela
T41.1X6A Underdosing of intravenous anesthetics, initial encounter
T41.1X6D Underdosing of intravenous anesthetics, subsequent encounter
T41.1X6S Underdosing of intravenous anesthetics, sequela

Group 20

(2 Codes)
Group 20 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81479 and Gene Test NAT2.

Group 20 Codes
CodeDescription
G70.80 Lambert-Eaton syndrome, unspecified
G70.81 Lambert-Eaton syndrome in disease classified elsewhere

Group 21

(70 Codes)
Group 21 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT code: 81479 and Gene Test Nonspecific (NAT).

Group 21 Codes
CodeDescription
A03.8 Other shigellosis
A03.9 Shigellosis, unspecified
A04.4 Other intestinal Escherichia coli infections
A15.9 Respiratory tuberculosis unspecified
A17.9 Tuberculosis of nervous system, unspecified
A18.01 Tuberculosis of spine
A18.02 Tuberculous arthritis of other joints
A18.03 Tuberculosis of other bones
A18.09 Other musculoskeletal tuberculosis
A18.10 Tuberculosis of genitourinary system, unspecified
A18.11 Tuberculosis of kidney and ureter
A18.12 Tuberculosis of bladder
A18.13 Tuberculosis of other urinary organs
A18.14 Tuberculosis of prostate
A18.15 Tuberculosis of other male genital organs
A18.16 Tuberculosis of cervix
A18.17 Tuberculous female pelvic inflammatory disease
A18.18 Tuberculosis of other female genital organs
A18.2 Tuberculous peripheral lymphadenopathy
A18.31 Tuberculous peritonitis
A18.32 Tuberculous enteritis
A18.39 Retroperitoneal tuberculosis
A18.4 Tuberculosis of skin and subcutaneous tissue
A18.50 Tuberculosis of eye, unspecified
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A18.7 Tuberculosis of adrenal glands
A18.81 Tuberculosis of thyroid gland
A18.82 Tuberculosis of other endocrine glands
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
A18.84 Tuberculosis of heart
A18.85 Tuberculosis of spleen
A18.89 Tuberculosis of other sites
A19.8 Other miliary tuberculosis
A19.9 Miliary tuberculosis, unspecified
B20 Human immunodeficiency virus [HIV] disease
B59 Pneumocystosis
B96.20 Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere
D84.89 Other immunodeficiencies
D84.9 Immunodeficiency, unspecified
E46 Unspecified protein-calorie malnutrition
H66.90 Otitis media, unspecified, unspecified ear
H66.93 Otitis media, unspecified, bilateral
J42 Unspecified chronic bronchitis
J62.8 Pneumoconiosis due to other dust containing silica
K27.4 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
K27.5 Chronic or unspecified peptic ulcer, site unspecified, with perforation
K27.6 Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage and perforation
K27.7 Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
K51.90 Ulcerative colitis, unspecified, without complications
K51.918 Ulcerative colitis, unspecified with other complication
K51.919 Ulcerative colitis, unspecified with unspecified complications
N18.6 End stage renal disease
N39.0 Urinary tract infection, site not specified
Z20.1 Contact with and (suspected) exposure to tuberculosis
Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Z22.7 Latent tuberculosis
Z85.6 Personal history of leukemia
Z85.819 Personal history of malignant neoplasm of unspecified site of lip, oral cavity, and pharynx
Z86.39 Personal history of other endocrine, nutritional and metabolic disease
Z90.3 Acquired absence of stomach [part of]
Z92.241 Personal history of systemic steroid therapy
Z92.25 Personal history of immunosuppression therapy
Z98.84 Bariatric surgery status

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

Group 1

Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes

N/A

ICD-10-PCS 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.

CodeDescription
99999 Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2022 R2

Article revised and published on 01/20/2022 effective for dates of service on and after 01/01/2022 to reflect the Annual HCPCS/CPT Code Updates. The following CPT codes have been added to the Article: 0286U in Table 1 for Gene/Test NUDT15, Table 2 for Gene NUDT15 and/or TPMT, ‘CPT/HCPCS Codes’ section for ‘Group 10 Codes’, and ‘ICD-10-CM Codes that Support Medical Necessity’ section for ‘Group 10 Paragraph’ and 0289U, 0290U, 0291U, 0292U, 0293U, and 0294U in the ‘CPT/HCPCS Codes’ section for ‘Group 22 Codes’.

12/12/2021 R1

Article revised and published on 12/09/2021 effective for dates of service on and after 12/12/2021. A paragraph was added to the ‘Coding Guidance’ section to address CPT codes 81355 (VKORC1) and 81227 (CYP2C9) not considered medically reasonable and necessary for warfarin testing with reference to NCD 90.1. The ‘ICD-10-CM Codes that Support Medical Necessity, Group 5’ for CPT code 81227 was revised to remove ICD-10 codes in this regard. This group was also revised to add ICD-10 codes in relation to Gene/Test CYP2C9 for phenytoin.

The sections for ‘CPT/HCPCS Codes’ and ‘ICD-10-CM Codes that Support Medical Necessity’, for ‘Group 13’ were deleted for CPT code 81355 and all subsequent groups were renumbered accordingly in both sections. CPT code 81355 was added to the ‘CPT codes Non-Covered for pharmacogenomic testing’ (Group 22).

A ‘CPT/HCPCS Modifier Table’ was added to include modifier 59.

Associated Documents

Related National Coverage Documents
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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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Other URLs
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Public Versions
Updated On Effective Dates Status
01/14/2022 01/01/2022 - N/A Currently in Effect You are here
12/03/2021 12/12/2021 - 12/31/2021 Superseded View
10/22/2021 12/12/2021 - N/A Superseded View

Keywords

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