Back to Local Coverage What's New Report Results

Local Coverage Article Billing and Coding

Billing and Coding: Pharmacogenomics Testing

A58801

Expand All | Collapse All

Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Novitas Solutions, Inc.	A and B MAC	04111 - MAC A	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04112 - MAC B	J - H	Colorado
Novitas Solutions, Inc.	A and B MAC	04211 - MAC A	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04212 - MAC B	J - H	New Mexico
Novitas Solutions, Inc.	A and B MAC	04311 - MAC A	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04312 - MAC B	J - H	Oklahoma
Novitas Solutions, Inc.	A and B MAC	04411 - MAC A	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04412 - MAC B	J - H	Texas
Novitas Solutions, Inc.	A and B MAC	04911 - MAC A	J - H	Colorado New Mexico Oklahoma Texas
Novitas Solutions, Inc.	A and B MAC	07101 - MAC A	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07102 - MAC B	J - H	Arkansas
Novitas Solutions, Inc.	A and B MAC	07201 - MAC A	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07202 - MAC B	J - H	Louisiana
Novitas Solutions, Inc.	A and B MAC	07301 - MAC A	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	07302 - MAC B	J - H	Mississippi
Novitas Solutions, Inc.	A and B MAC	12101 - MAC A	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12102 - MAC B	J - L	Delaware
Novitas Solutions, Inc.	A and B MAC	12201 - MAC A	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12202 - MAC B	J - L	District of Columbia
Novitas Solutions, Inc.	A and B MAC	12301 - MAC A	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12302 - MAC B	J - L	Maryland
Novitas Solutions, Inc.	A and B MAC	12401 - MAC A	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12402 - MAC B	J - L	New Jersey
Novitas Solutions, Inc.	A and B MAC	12501 - MAC A	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12502 - MAC B	J - L	Pennsylvania
Novitas Solutions, Inc.	A and B MAC	12901 - MAC A	J - L	Delaware District of Columbia Maryland New Jersey Pennsylvania

Article Information

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

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.

Copyright © 2013 - 2021, the American Hospital Association, Chicago, Illinois. Reproduced by CMS 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. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

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

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
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.
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.
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.
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

Expand All | Collapse All

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

Code	Description
81220	Cftr gene com variants

Group 2

(1 Code)

Group 2 Paragraph

N/A

Group 2 Codes

Code	Description
81225	Cyp2c19 gene com variants

Group 3

(8 Codes)

Group 3 Paragraph

N/A

Group 3 Codes

Code	Description
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

Code	Description
81226	Cyp2d6 gene com variants

Group 5

(1 Code)

Group 5 Paragraph

N/A

Group 5 Codes

Code	Description
81227	Cyp2c9 gene com variants

Group 6

(1 Code)

Group 6 Paragraph

N/A

Group 6 Codes

Code	Description
81231	Cyp3a5 gene common variants

Group 7

(1 Code)

Group 7 Paragraph

N/A

Group 7 Codes

Code	Description
81232	Dpyd gene common variants

Group 8

(1 Code)

Group 8 Paragraph

N/A

Group 8 Codes

Code	Description
81247	G6pd gene alys cmn variant

Group 9

(1 Code)

Group 9 Paragraph

N/A

Group 9 Codes

Code	Description
81283	Ifnl3 gene

Group 10

(3 Codes)

Group 10 Paragraph

N/A

Group 10 Codes

Code	Description
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

Code	Description
81328	Slco1b1 gene com variants

Group 12

(1 Code)

Group 12 Paragraph

N/A

Group 12 Codes

Code	Description
81350	Ugt1a1 gene common variants

Group 13

(2 Codes)

Group 13 Paragraph

N/A

Group 13 Codes

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Code	Description
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

Expand All | Collapse All

Group 1

(1 Code)

Group 1 Paragraph

N/A

Group 1 Codes

Code	Description
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

Expand All | Collapse All

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

Code	Description
E84.8	Cystic fibrosis with other manifestations

Group 2

(67 Codes)

Group 2 Paragraph

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

Group 2 Codes

Code	Description
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

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

Code	Description
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

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

Group 4 Codes

Code	Description
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

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

Group 5 Codes

Code	Description
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

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

Group 6 Codes

Code	Description
Z94.0	Kidney transplant status
Z94.1	Heart transplant status
Z94.4	Liver transplant status

Group 7

(7 Codes)

Group 7 Paragraph

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

Group 7 Codes

Code	Description
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

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

Group 8 Codes

Code	Description
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

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

Group 9 Codes

Code	Description
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

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

Group 10 Codes

Code	Description
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

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

Group 11 Codes

Code	Description
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

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

Group 12 Codes

Code	Description
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

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

Group 13 Codes

Code	Description
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

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

Group 14 Codes

Code	Description
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

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

Group 15 Codes

Code	Description
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

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

Group 16 Codes

Code	Description
B20	Human immunodeficiency virus [HIV] disease

Group 17

(36 Codes)

Group 17 Paragraph

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

Group 17 Codes

Code	Description
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

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

Group 18 Codes

Code	Description
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

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

Group 19 Codes

Code	Description
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

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

Group 20 Codes

Code	Description
G70.80	Lambert-Eaton syndrome, unspecified
G70.81	Lambert-Eaton syndrome in disease classified elsewhere

Group 21

(70 Codes)

Group 21 Paragraph

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

Group 21 Codes

Code	Description
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

Expand All | Collapse All

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.

Code	Description
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.

Code	Description
99999	Not Applicable

Other Coding Information

N/A

Revision History Information

Revision History Date	Revision History Number	Revision 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

Keywords

N/A

Read the Article Disclaimer

Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes.

LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT")

End User Point and Click Amendment:

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of CMS internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by the Centers for Medicare and Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site, http://www.ama-assn.org/cpt.

Applicable FARS\DFARS Restrictions Apply to Government Use.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "I Accept".

LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY (CDT^TM)

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. By clicking below on the button labeled "I accept", you hereby acknowledge that you have read, understood and agreed to all terms and conditions set forth in this agreement.

If you do not agree with all terms and conditions set forth herein, click below on the button labeled "I do not accept" and exit from this computer screen.

If you are acting on behalf of an organization, you represent that you are authorized to act on behalf of such organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.
Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. U.S. Government Rights Provisions.
Organizations who contract with CMS acknowledge that they may have a commercial CDT license with the ADA, and that use of CDT codes as permitted herein for the administration of CMS programs does not extend to any other programs or services the organization may administer and royalties dues for the use of the CDT codes are governed by their commercial license.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for software, including any CDT and other content contained therein, is with CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement.

The ADA is a third party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS disclaims responsibility for any liability attributable to end user use of the CDT. CMS will not be liable for any claims attributable to any errors, omissions, or other inaccuracies in the information or material covered by this license. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I Accept". If you do not agree to the terms and conditions, you may not access or use software. Instead you must click below on the button labeled "I Do Not Accept" and exit from this computer screen.

LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)

American Hospital Association Disclaimer

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.

Submit Feedback/Ask a Question

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
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Billing and Coding: Pharmacogenomics Testing

Contractor Information

Article Information

General Information

CMS National Coverage Policy

Article Guidance

Coding Information

CPT/HCPCS Codes

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7

Group 8

Group 9

Group 10

Group 11

Group 12

Group 13

Group 14

Group 15

Group 16

Group 17

Group 18

Group 19

Group 20

Group 21

Group 22

CPT/HCPCS Modifiers

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7

Group 8

Group 9

Group 10

Group 11

Group 12

Group 13

Group 14

Group 15

Group 16

Group 17

Group 18

Group 19

Group 20

Group 21

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

Group 1

ICD-10-PCS Codes

Additional ICD-10 Information

Bill Type Codes

Revenue Codes

Other Coding Information

Revision History Information

Associated Documents

Keywords

Page Help for Article - Billing and Coding: Pharmacogenomics Testing (A58801)

Introduction

Finding a specific code

Printing a Document to PDF

More information

Get email updates

CMS & HHS WEBSITES

HELPFUL LINKS

RSS FEEDS