SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Pharmacogenomics Testing

A58812

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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General Information

Source Article ID
N/A
Article ID
A58812
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Pharmacogenomics Testing
Article Type
Billing and Coding
Original Effective Date
12/12/2021
Revision Effective Date
07/01/2023
Revision Ending Date
09/30/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Internet Only Manuals (IOMs):

  • 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):

  • 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) L39073 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 A58918 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.

When billing CPT code 81418, the following information should be provided:

  • List the names of the specific genes that are tested in addition to genes CYP2C19 and CYP2D6 in the comment/narrative field for the following claim field/types:
    • Part A Claims:
      • Loop SV202-7 for the 837I electronic claim
      • Block 80 for the UB04 claim form
    • Part B Claims:
      • Loop 2400 or SV101-7 for the 5010A1 837P
      • Box 19 for the paper claim

NOTE: Testing MUST be for at least 6 genes per the CPT code descriptor for 81418: Drug metabolism (e.g., pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis

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 October 26, 2022:

Gene/Test

CPT Code

Intended use for Drug

Brand Name

CFTR

81220

ivacaftor

Kalydeco

CYP2B6

81479, 0392U

efavirenz, sertraline

Sustiva, Zoloft

CYP2C19

81225, 81418

clopidogrel, voriconazole

Plavix, Vfend

CYP2C19

81225, 81418

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

Prilosec, Prevacid, Protonix, Dexilant

CYP2C19

81225, 81418

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

Celexa, Lexapro, Luvox, Paxil, Zoloft

CYP2C19

81225, 81418

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

Anafranil, Norpramin, Silenor,
Pamelor, Surmontil

CYP2C9

81227

phenytoin, fosphenytoin

Dilantin, Cerebyx

CYP2C9

81227

warfarin

Jantoven, Coumadin

CYP2C9

81227

NSAIDs (class): celecoxib, flurbiprofen, ibuprofen, lornoxicam, meloxicam, piroxicam, tenoxicam

Celebrex, Ocufen, Chlortenoxicam, Mobic, Feldene, Mobiflex

CYP2C9

81227

fluvastatin

Lescol

HLA-B

81381, 81374

abacavir, allopurinol, oxcarbazepine, phenytoin, carbamazepine, fosphenytoin

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

CYP4F2

81479

warfarin

Jantoven, Coumadin

VKORC1

81355

warfarin

Jantoven, Coumadin

CYP2D6

81226, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

atomoxetine, codeine, ondansetron, tropisetron, tamoxifen, tramadol, hydrocodone

Strattera, Zofran, Soltamox, Ultram

CYP2D6

81226, 81418, 0392U

venlafaxine

Effexor

CYP2D6

81226, 81418, 0392U

vortioxetine

Trintellix

CYP2D6

81226, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

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

Celexa, Lexapro, Luvox, Paxil, Zoloft

CYP2D6

81226, 81418, 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

Adrucil, Xeloda

G6PD

81247

rasburicase

Elitek

G6PD

81247

dapsone, methylene blue, nitrofurantoin, pegloticase, primaquine, tafenoquine

Aczone, Provayblue, Furadantin, Macrobid, Macrodantin, Krystexxa, Primaquine, Arakoda, Krintafel

HLA-A

81381, 81374

carbamazepine

Tegretol

IFNL3

81283

peginterferon alfa-2a, peginterferon alfa-2b

Pegasys, Pegintron, Sylatron

IFNL4

81479

peginterferon alfa-2a, peginterferon alfa-2b

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

Statins (class): simvastatin, pravastatin, atorvastatin, lovastatin, rosuvastatin, fluvastatin, pitavastatin

Zocor, FloLipid, Pravachol, Lipitor, Altoprev, Crestor, Lescol, Livalo

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

MT-RNR1

81401

Aminoglycosides (class): gentamicin, amikacin, paromomycin, streptomycin, plazomicin, tobramycin

Arikayce, Zemdri

ABCG2

0193U

rosuvastatin

Crestor



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 October 26, 2022):

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, 81418

brivaracetam

Briviact

intermediate or poor metabolizers

CYP2C19

81225, 81418

citalopram

Celexa

poor metabolizers

CYP2C19

81225, 81418

clobazam

Onfi

intermediate or poor metabolizers

CYP2C19

81225, 81418

clopidogrel

Plavix

intermediate or poor metabolizers

CYP2C19

81225, 81418

flibanserin

Addyi

poor metabolizers

CYP2C19

81225, 81418

pantoprazole

Protonix

Intermediate or poor metabolizers

CYP2C19

81225, 81418

voriconazole

Vfend

intermediate or poor metabolizers

CYP2C19

81225, 81418

abrocitinib

Cibinqo

poor metabolizers

CYP2C19

81225, 81418

mavacamten

Camzyos

intermediate or poor metabolizers

CYP2C19 and/or UGT2B17

81225, 81418

belzutifan

Cibinqo

poor metabolizers

CYP2C9

81227

celecoxib

Celebrex

poor metabolizers or *3 carriers

CYP2C9

81227

dronabinol

Marinol

intermediate or poor metabolizers

CYP2C9

81227

erdafitinib

Balversa

*3/*3 (poor metabolizers)

CYP2C9

81227

flurbiprofen

Ansaid

poor metabolizers or *3 carriers

CYP2C9

81227

fosphenytoin

Cerebyx

intermediate or poor metabolizers

CYP2C9

81227

meloxicam

Mobic

poor metabolizers or *3 carriers

CYP2C9

81227

nateglinide

 

poor metabolizers

CYP2C9

81227

phenytoin

Dilantin

intermediate or 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, 81418

amphetamine

Adderall

poor metabolizers

CYP2D6

81226, 81418

aripiprazole

Abilify

poor metabolizers

CYP2D6

81226, 81418

aripiprazole lauroxil

Aristada

poor metabolizers

CYP2D6

81226, 81418

atomoxetine

Strattera

poor metabolizers

CYP2D6

81226, 81418

brexpiprazole

Rexulti

poor metabolizers

CYP2D6

81226, 81418

clozapine

Clozaril, FazaClo, Versacloz

poor metabolizers

CYP2D6

81226, 81418

codeine

 

ultrarapid metabolizers, poor metabolizers

CYP2D6

81226, 81418

deutetrabenazine

Austedo

poor metabolizers

CYP2D6

81226, 81418

eliglustat

Cerdelga

ultrarapid, normal, intermediate, or poor metabolizers

CYP2D6

81226, 81418

gefitinib

Iressa

poor metabolizers

CYP2D6

81226, 81418

Iloperidone

Fanapt

poor metabolizers

CYP2D6

81226, 81418

lofexidine

Lucemyra

poor metabolizers

CYP2D6

81226, 81418

meclizine

Antivert

ultrarapid, intermediate, or poor metabolizers

CYP2D6

81226, 81418

metoclopramide

Reglan

poor metabolizers

CYP2D6

81226, 81418

pimozide

Orap

poor metabolizers

CYP2D6

81226, 81418

propafenone

Rythmol

poor metabolizers

CYP2D6

81226, 81418

tetrabenazine

Xenazine

poor metabolizers

CYP2D6

81226, 81418

thioridazine

Mellaril

poor metabolizers

CYP2D6

81226, 81418

tramadol

Ultram

ultrarapid metabolizers, or poor metabolizers

CYP2D6

81226, 81418

valbenazine

Ingrezza

poor metabolizers

CYP2D6

81226, 81418

venlafaxine

Effexor

poor metabolizers

CYP2D6

81226, 81418

vortioxetine

Trintellix

poor metabolizers

CYP2D6

81226, 81418

carvedilol

Coreg

poor metabolizers

CYP2D6

81226, 81418

cevimeline

Evoxac

poor metabolizers

CYP2D6

81226, 81418

perphenazine

Trilafon

poor metabolizers

CYP2D6

81226, 81418

tolterodine

Detrol

poor metabolizers

CYP2D6

81226, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

oliceridine

Olinvyk

poor metabolizers

CYP2D6

81226, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

pitolisant

Wakix

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

fosphenytoin

Cerebyx

*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-B

81381, 81374

phenytoin

Dilantin

*15:02 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

*1/*6, *1/*28 (intermediate metabolizers) or *6/*6, *6/*28, *28/*28 (poor metabolizers)

UGT1A1

81350

nilotinib

Tasigna

*28/*28 (poor metabolizers)

UGT1A1

81350

pazopanib

Votrient

*28/*28 (poor metabolizers)

UGT1A1

81350

sacituzumab
govitecan-hziy

Trodelvy

*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).

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

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
Code Description
81220 Cftr gene com variants

Group 2

(2 Codes)
Group 2 Paragraph

N/A

Group 2 Codes
Code Description
81225 Cyp2c19 gene com variants
81418 Rx metab gen seq alys pnl 6

Group 3

(9 Codes)
Group 3 Paragraph

N/A

Group 3 Codes
Code Description
81226 Cyp2d6 gene com variants
81418 Rx metab gen seq alys pnl 6
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

(3 Codes)
Group 4 Paragraph

N/A

Group 4 Codes
Code Description
81226 Cyp2d6 gene com variants
81418 Rx metab gen seq alys pnl 6
0392U Rx metab gen-rx ia 16 genes

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
81401 Mopath procedure level 2

Group 16

(1 Code)
Group 16 Paragraph

N/A

Group 16 Codes
Code Description
81406 Mopath procedure level 7

Group 17

(2 Codes)
Group 17 Paragraph

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

Group 17 Codes
Code Description
81479 Unlisted molecular pathology
0392U Rx metab gen-rx ia 16 genes

Group 18

(1 Code)
Group 18 Paragraph

Report code 81479 and gene test CYP4F2 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 CACNA1S 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 BCHE 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 IFNL4 in the claim narrative/remarks.

Group 21 Codes
Code Description
81479 Unlisted molecular pathology

Group 22

(1 Code)
Group 22 Paragraph

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

Group 22 Codes
Code Description
81479 Unlisted molecular pathology

Group 23

(1 Code)
Group 23 Paragraph

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

Group 23 Codes
Code Description
81479 Unlisted molecular pathology

Group 24

(1 Code)
Group 24 Paragraph

N/A

Group 24 Codes
Code Description
0193U Jr gnotyp abcg2 exons 2-26

Group 25

(12 Codes)
Group 25 Paragraph

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

Group 25 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
N/A

CPT/HCPCS Modifiers

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.
N/A

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
Code Description
E84.8 Cystic fibrosis with other manifestations

Group 2

(99 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 codes: 81225 and 81418.

Group 2 Codes
Code Description
B37.81 Candidal esophagitis
B37.89 Other sites of candidiasis
B44.0 Invasive pulmonary aspergillosis
B48.8* Other specified mycoses
C25.4* Malignant neoplasm of endocrine pancreas
C64.1* Malignant neoplasm of right kidney, except renal pelvis
C64.2* Malignant neoplasm of left kidney, except renal pelvis
C65.1* Malignant neoplasm of right renal pelvis
C65.2* Malignant neoplasm of left renal pelvis
C66.1* Malignant neoplasm of right ureter
C66.2* Malignant neoplasm of left ureter
C67.0* Malignant neoplasm of trigone of bladder
C67.1* Malignant neoplasm of dome of bladder
C67.2* Malignant neoplasm of lateral wall of bladder
C67.3* Malignant neoplasm of anterior wall of bladder
C67.4* Malignant neoplasm of posterior wall of bladder
C67.5* Malignant neoplasm of bladder neck
C67.6* Malignant neoplasm of ureteric orifice
C67.7* Malignant neoplasm of urachus
C67.8* Malignant neoplasm of overlapping sites of bladder
C68.0* Malignant neoplasm of urethra
C68.1* Malignant neoplasm of paraurethral glands
C68.8* Malignant neoplasm of overlapping sites of urinary organs
C7A.093* Malignant carcinoid tumor of the kidney
D13.7* Benign neoplasm of endocrine pancreas
D18.02* Hemangioma of intracranial structures
D32.0* Benign neoplasm of cerebral meninges
D32.1* Benign neoplasm of spinal meninges
D33.0* Benign neoplasm of brain, supratentorial
D33.1* Benign neoplasm of brain, infratentorial
D33.3* Benign neoplasm of cranial nerves
D33.4* Benign neoplasm of spinal cord
D33.7* Benign neoplasm of other specified parts of central nervous system
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
F32.81 Premenstrual dysphoric disorder
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
I42.1 Obstructive hypertrophic cardiomyopathy
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
L20.89 Other atopic dermatitis
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 B48.8 must be reported with ICD-10 code Z16.32.
*Dual diagnosis requirement: ICD-10 code F52.0 must be reported with ICD-10 code N95.8.
*Dual diagnosis requirement: ICD-10-CM code Q85.83 must be billed with ICD-10-CM code C25.4, C64.1, C64.2, C65.1, C65.2, C66.1, C66.2, C67.0, C67.1, C67.2, C67.3, C67.4, C67.5, C67.6, C67.7, C67.8, C68.0, C68.1, C68.8, C7A.093, D13.7, D18.02, D32.0, D32.1, D33.0, D33.1, D33.3, D33.4 OR D33.7.

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, 81418, 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
F32.81 Premenstrual dysphoric disorder
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
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
R11.2* Nausea with vomiting, unspecified
R52 Pain, unspecified
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

(79 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 codes: 81226,  81418, and 0392U.

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
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
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
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 an ICD-10 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 R11.2 must be reported with ICD-10 code Z48.89, Z51.0 or Z92.21.

*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

(24 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
Code Description
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
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
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
M06.8A Other specified rheumatoid arthritis, other specified site
M19.09 Primary osteoarthritis, other specified site
M19.29 Secondary osteoarthritis, other specified site
T38.3X5A Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter
Z48.811 Encounter for surgical aftercare following surgery on the nervous system
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 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
Code Description
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
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

(168 Codes)
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
Code Description
B51.0 Plasmodium vivax malaria with rupture of spleen
B51.8 Plasmodium vivax malaria with other complications
B51.9 Plasmodium vivax malaria without complication
D74.8 Other methemoglobinemias
E79.9* Disorder of purine and pyrimidine metabolism, unspecified
L70.0 Acne vulgaris
M1A.0110 Idiopathic chronic gout, right shoulder, without tophus (tophi)
M1A.0111 Idiopathic chronic gout, right shoulder, with tophus (tophi)
M1A.0120 Idiopathic chronic gout, left shoulder, without tophus (tophi)
M1A.0121 Idiopathic chronic gout, left shoulder, with tophus (tophi)
M1A.0210 Idiopathic chronic gout, right elbow, without tophus (tophi)
M1A.0211 Idiopathic chronic gout, right elbow, with tophus (tophi)
M1A.0220 Idiopathic chronic gout, left elbow, without tophus (tophi)
M1A.0221 Idiopathic chronic gout, left elbow, with tophus (tophi)
M1A.0310 Idiopathic chronic gout, right wrist, without tophus (tophi)
M1A.0311 Idiopathic chronic gout, right wrist, with tophus (tophi)
M1A.0320 Idiopathic chronic gout, left wrist, without tophus (tophi)
M1A.0321 Idiopathic chronic gout, left wrist, with tophus (tophi)
M1A.0410 Idiopathic chronic gout, right hand, without tophus (tophi)
M1A.0411 Idiopathic chronic gout, right hand, with tophus (tophi)
M1A.0420 Idiopathic chronic gout, left hand, without tophus (tophi)
M1A.0421 Idiopathic chronic gout, left hand, with tophus (tophi)
M1A.0510 Idiopathic chronic gout, right hip, without tophus (tophi)
M1A.0511 Idiopathic chronic gout, right hip, with tophus (tophi)
M1A.0520 Idiopathic chronic gout, left hip, without tophus (tophi)
M1A.0521 Idiopathic chronic gout, left hip, with tophus (tophi)
M1A.0610 Idiopathic chronic gout, right knee, without tophus (tophi)
M1A.0611 Idiopathic chronic gout, right knee, with tophus (tophi)
M1A.0620 Idiopathic chronic gout, left knee, without tophus (tophi)
M1A.0621 Idiopathic chronic gout, left knee, with tophus (tophi)
M1A.0710 Idiopathic chronic gout, right ankle and foot, without tophus (tophi)
M1A.0711 Idiopathic chronic gout, right ankle and foot, with tophus (tophi)
M1A.0720 Idiopathic chronic gout, left ankle and foot, without tophus (tophi)
M1A.0721 Idiopathic chronic gout, left ankle and foot, with tophus (tophi)
M1A.08X0 Idiopathic chronic gout, vertebrae, without tophus (tophi)
M1A.08X1 Idiopathic chronic gout, vertebrae, with tophus (tophi)
M1A.09X0 Idiopathic chronic gout, multiple sites, without tophus (tophi)
M1A.09X1 Idiopathic chronic gout, multiple sites, with tophus (tophi)
M1A.1110 Lead-induced chronic gout, right shoulder, without tophus (tophi)
M1A.1111 Lead-induced chronic gout, right shoulder, with tophus (tophi)
M1A.1120 Lead-induced chronic gout, left shoulder, without tophus (tophi)
M1A.1121 Lead-induced chronic gout, left shoulder, with tophus (tophi)
M1A.1210 Lead-induced chronic gout, right elbow, without tophus (tophi)
M1A.1211 Lead-induced chronic gout, right elbow, with tophus (tophi)
M1A.1220 Lead-induced chronic gout, left elbow, without tophus (tophi)
M1A.1221 Lead-induced chronic gout, left elbow, with tophus (tophi)
M1A.1310 Lead-induced chronic gout, right wrist, without tophus (tophi)
M1A.1311 Lead-induced chronic gout, right wrist, with tophus (tophi)
M1A.1320 Lead-induced chronic gout, left wrist, without tophus (tophi)
M1A.1321 Lead-induced chronic gout, left wrist, with tophus (tophi)
M1A.1410 Lead-induced chronic gout, right hand, without tophus (tophi)
M1A.1411 Lead-induced chronic gout, right hand, with tophus (tophi)
M1A.1420 Lead-induced chronic gout, left hand, without tophus (tophi)
M1A.1421 Lead-induced chronic gout, left hand, with tophus (tophi)
M1A.1510 Lead-induced chronic gout, right hip, without tophus (tophi)
M1A.1511 Lead-induced chronic gout, right hip, with tophus (tophi)
M1A.1520 Lead-induced chronic gout, left hip, without tophus (tophi)
M1A.1521 Lead-induced chronic gout, left hip, with tophus (tophi)
M1A.1610 Lead-induced chronic gout, right knee, without tophus (tophi)
M1A.1611 Lead-induced chronic gout, right knee, with tophus (tophi)
M1A.1620 Lead-induced chronic gout, left knee, without tophus (tophi)
M1A.1621 Lead-induced chronic gout, left knee, with tophus (tophi)
M1A.1710 Lead-induced chronic gout, right ankle and foot, without tophus (tophi)
M1A.1711 Lead-induced chronic gout, right ankle and foot, with tophus (tophi)
M1A.1720 Lead-induced chronic gout, left ankle and foot, without tophus (tophi)
M1A.1721 Lead-induced chronic gout, left ankle and foot, with tophus (tophi)
M1A.18X0 Lead-induced chronic gout, vertebrae, without tophus (tophi)
M1A.18X1 Lead-induced chronic gout, vertebrae, with tophus (tophi)
M1A.19X0 Lead-induced chronic gout, multiple sites, without tophus (tophi)
M1A.19X1 Lead-induced chronic gout, multiple sites, with tophus (tophi)
M1A.2110 Drug-induced chronic gout, right shoulder, without tophus (tophi)
M1A.2111 Drug-induced chronic gout, right shoulder, with tophus (tophi)
M1A.2120 Drug-induced chronic gout, left shoulder, without tophus (tophi)
M1A.2121 Drug-induced chronic gout, left shoulder, with tophus (tophi)
M1A.2210 Drug-induced chronic gout, right elbow, without tophus (tophi)
M1A.2211 Drug-induced chronic gout, right elbow, with tophus (tophi)
M1A.2220 Drug-induced chronic gout, left elbow, without tophus (tophi)
M1A.2221 Drug-induced chronic gout, left elbow, with tophus (tophi)
M1A.2310 Drug-induced chronic gout, right wrist, without tophus (tophi)
M1A.2311 Drug-induced chronic gout, right wrist, with tophus (tophi)
M1A.2320 Drug-induced chronic gout, left wrist, without tophus (tophi)
M1A.2321 Drug-induced chronic gout, left wrist, with tophus (tophi)
M1A.2410 Drug-induced chronic gout, right hand, without tophus (tophi)
M1A.2411 Drug-induced chronic gout, right hand, with tophus (tophi)
M1A.2420 Drug-induced chronic gout, left hand, without tophus (tophi)
M1A.2421 Drug-induced chronic gout, left hand, with tophus (tophi)
M1A.2510 Drug-induced chronic gout, right hip, without tophus (tophi)
M1A.2511 Drug-induced chronic gout, right hip, with tophus (tophi)
M1A.2520 Drug-induced chronic gout, left hip, without tophus (tophi)
M1A.2521 Drug-induced chronic gout, left hip, with tophus (tophi)
M1A.2610 Drug-induced chronic gout, right knee, without tophus (tophi)
M1A.2611 Drug-induced chronic gout, right knee, with tophus (tophi)
M1A.2620 Drug-induced chronic gout, left knee, without tophus (tophi)
M1A.2621 Drug-induced chronic gout, left knee, with tophus (tophi)
M1A.2710 Drug-induced chronic gout, right ankle and foot, without tophus (tophi)
M1A.2711 Drug-induced chronic gout, right ankle and foot, with tophus (tophi)
M1A.2720 Drug-induced chronic gout, left ankle and foot, without tophus (tophi)
M1A.2721 Drug-induced chronic gout, left ankle and foot, with tophus (tophi)
M1A.28X0 Drug-induced chronic gout, vertebrae, without tophus (tophi)
M1A.28X1 Drug-induced chronic gout, vertebrae, with tophus (tophi)
M1A.29X0 Drug-induced chronic gout, multiple sites, without tophus (tophi)
M1A.29X1 Drug-induced chronic gout, multiple sites, with tophus (tophi)
M1A.3110 Chronic gout due to renal impairment, right shoulder, without tophus (tophi)
M1A.3111 Chronic gout due to renal impairment, right shoulder, with tophus (tophi)
M1A.3120 Chronic gout due to renal impairment, left shoulder, without tophus (tophi)
M1A.3121 Chronic gout due to renal impairment, left shoulder, with tophus (tophi)
M1A.3210 Chronic gout due to renal impairment, right elbow, without tophus (tophi)
M1A.3211 Chronic gout due to renal impairment, right elbow, with tophus (tophi)
M1A.3220 Chronic gout due to renal impairment, left elbow, without tophus (tophi)
M1A.3221 Chronic gout due to renal impairment, left elbow, with tophus (tophi)
M1A.3310 Chronic gout due to renal impairment, right wrist, without tophus (tophi)
M1A.3311 Chronic gout due to renal impairment, right wrist, with tophus (tophi)
M1A.3320 Chronic gout due to renal impairment, left wrist, without tophus (tophi)
M1A.3321 Chronic gout due to renal impairment, left wrist, with tophus (tophi)
M1A.3410 Chronic gout due to renal impairment, right hand, without tophus (tophi)
M1A.3411 Chronic gout due to renal impairment, right hand, with tophus (tophi)
M1A.3420 Chronic gout due to renal impairment, left hand, without tophus (tophi)
M1A.3421 Chronic gout due to renal impairment, left hand, with tophus (tophi)
M1A.3510 Chronic gout due to renal impairment, right hip, without tophus (tophi)
M1A.3511 Chronic gout due to renal impairment, right hip, with tophus (tophi)
M1A.3520 Chronic gout due to renal impairment, left hip, without tophus (tophi)
M1A.3521 Chronic gout due to renal impairment, left hip, with tophus (tophi)
M1A.3610 Chronic gout due to renal impairment, right knee, without tophus (tophi)
M1A.3611 Chronic gout due to renal impairment, right knee, with tophus (tophi)
M1A.3620 Chronic gout due to renal impairment, left knee, without tophus (tophi)
M1A.3621 Chronic gout due to renal impairment, left knee, with tophus (tophi)
M1A.3710 Chronic gout due to renal impairment, right ankle and foot, without tophus (tophi)
M1A.3711 Chronic gout due to renal impairment, right ankle and foot, with tophus (tophi)
M1A.3720 Chronic gout due to renal impairment, left ankle and foot, without tophus (tophi)
M1A.3721 Chronic gout due to renal impairment, left ankle and foot, with tophus (tophi)
M1A.38X0 Chronic gout due to renal impairment, vertebrae, without tophus (tophi)
M1A.38X1 Chronic gout due to renal impairment, vertebrae, with tophus (tophi)
M1A.39X0 Chronic gout due to renal impairment, multiple sites, without tophus (tophi)
M1A.39X1 Chronic gout due to renal impairment, multiple sites, with tophus (tophi)
M1A.4110 Other secondary chronic gout, right shoulder, without tophus (tophi)
M1A.4111 Other secondary chronic gout, right shoulder, with tophus (tophi)
M1A.4120 Other secondary chronic gout, left shoulder, without tophus (tophi)
M1A.4121 Other secondary chronic gout, left shoulder, with tophus (tophi)
M1A.4210 Other secondary chronic gout, right elbow, without tophus (tophi)
M1A.4211 Other secondary chronic gout, right elbow, with tophus (tophi)
M1A.4220 Other secondary chronic gout, left elbow, without tophus (tophi)
M1A.4221 Other secondary chronic gout, left elbow, with tophus (tophi)
M1A.4310 Other secondary chronic gout, right wrist, without tophus (tophi)
M1A.4311 Other secondary chronic gout, right wrist, with tophus (tophi)
M1A.4320 Other secondary chronic gout, left wrist, without tophus (tophi)
M1A.4321 Other secondary chronic gout, left wrist, with tophus (tophi)
M1A.4410 Other secondary chronic gout, right hand, without tophus (tophi)
M1A.4411 Other secondary chronic gout, right hand, with tophus (tophi)
M1A.4420 Other secondary chronic gout, left hand, without tophus (tophi)
M1A.4421 Other secondary chronic gout, left hand, with tophus (tophi)
M1A.4510 Other secondary chronic gout, right hip, without tophus (tophi)
M1A.4511 Other secondary chronic gout, right hip, with tophus (tophi)
M1A.4520 Other secondary chronic gout, left hip, without tophus (tophi)
M1A.4521 Other secondary chronic gout, left hip, with tophus (tophi)
M1A.4610 Other secondary chronic gout, right knee, without tophus (tophi)
M1A.4611 Other secondary chronic gout, right knee, with tophus (tophi)
M1A.4620 Other secondary chronic gout, left knee, without tophus (tophi)
M1A.4621 Other secondary chronic gout, left knee, with tophus (tophi)
M1A.4710 Other secondary chronic gout, right ankle and foot, without tophus (tophi)
M1A.4711 Other secondary chronic gout, right ankle and foot, with tophus (tophi)
M1A.4720 Other secondary chronic gout, left ankle and foot, without tophus (tophi)
M1A.4721 Other secondary chronic gout, left ankle and foot, with tophus (tophi)
M1A.48X0 Other secondary chronic gout, vertebrae, without tophus (tophi)
M1A.48X1 Other secondary chronic gout, vertebrae, 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)
N30.00* Acute cystitis without hematuria
N30.01* Acute cystitis with hematuria
Group 8 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual Diagnosis Requirement: ICD-10 code N30.00 or N30.01 must be reported with ICD-10 code B95.2, B95.61, B95.62, B95.7, B96.1, B96.21, B96.22, B96.29 OR B96.89.

*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

(23 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
Code Description
B18.0* Chronic viral hepatitis B with delta-agent
B18.1* Chronic viral hepatitis B without delta-agent
B18.2* Chronic viral hepatitis C
C43.0* Malignant melanoma of lip
C43.111* Malignant melanoma of right upper eyelid, including canthus
C43.112* Malignant melanoma of right lower eyelid, including canthus
C43.121* Malignant melanoma of left upper eyelid, including canthus
C43.122* Malignant melanoma of left lower eyelid, including canthus
C43.21* Malignant melanoma of right ear and external auricular canal
C43.22* Malignant melanoma of left ear and external auricular canal
C43.31* Malignant melanoma of nose
C43.39* Malignant melanoma of other parts of face
C43.4* Malignant melanoma of scalp and neck
C43.51* Malignant melanoma of anal skin
C43.52* Malignant melanoma of skin of breast
C43.59* Malignant melanoma of other part of trunk
C43.61* Malignant melanoma of right upper limb, including shoulder
C43.62* Malignant melanoma of left upper limb, including shoulder
C43.71* Malignant melanoma of right lower limb, including hip
C43.72* Malignant melanoma of left lower limb, including hip
C43.8* Malignant melanoma of overlapping sites of skin
C43.9* Malignant melanoma of skin, unspecified
K73.9* Chronic hepatitis, unspecified
Group 9 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: ICD-10 code B18.0, B18.1, B18.2 or K73.9 must be reported with ICD-10 code K76.9 to indicate compensated liver disease.

*Dual diagnosis requirement: ICD-10 code C43.0, C43.111, C43.112, C43.121, C43.122, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8 or C43.9 must be reported with ICD-10 code C77.9 to indicate nodal involvement.

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
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

(11 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
Code Description
E11.8* Type 2 diabetes mellitus with unspecified complications
E11.9* Type 2 diabetes mellitus without complications
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
E78.49 Other hyperlipidemia
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
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 11 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report ICD-10 code E11.8 or E11.9 with ICD-10 code(s) to indicate multiple risk factors for cardiovascular heart disease (e.g., E78.2, E78.49, I10, Z68.25-Z68.45, Z72.0, Z82.49).

Group 12

(62 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
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
C50.011* Malignant neoplasm of nipple and areola, right female breast
C50.012* Malignant neoplasm of nipple and areola, left female breast
C50.021* Malignant neoplasm of nipple and areola, right male breast
C50.022* Malignant neoplasm of nipple and areola, left male breast
C50.111* Malignant neoplasm of central portion of right female breast
C50.112* Malignant neoplasm of central portion of left female breast
C50.121* Malignant neoplasm of central portion of right male breast
C50.122* Malignant neoplasm of central portion of left male breast
C50.211* Malignant neoplasm of upper-inner quadrant of right female breast
C50.212* Malignant neoplasm of upper-inner quadrant of left female breast
C50.221* Malignant neoplasm of upper-inner quadrant of right male breast
C50.222* Malignant neoplasm of upper-inner quadrant of left male breast
C50.311* Malignant neoplasm of lower-inner quadrant of right female breast
C50.312* Malignant neoplasm of lower-inner quadrant of left female breast
C50.321* Malignant neoplasm of lower-inner quadrant of right male breast
C50.322* Malignant neoplasm of lower-inner quadrant of left male breast
C50.411* Malignant neoplasm of upper-outer quadrant of right female breast
C50.412* Malignant neoplasm of upper-outer quadrant of left female breast
C50.421* Malignant neoplasm of upper-outer quadrant of right male breast
C50.422* Malignant neoplasm of upper-outer quadrant of left male breast
C50.511* Malignant neoplasm of lower-outer quadrant of right female breast
C50.512* Malignant neoplasm of lower-outer quadrant of left female breast
C50.521* Malignant neoplasm of lower-outer quadrant of right male breast
C50.522* Malignant neoplasm of lower-outer quadrant of left male breast
C50.611* Malignant neoplasm of axillary tail of right female breast
C50.612* Malignant neoplasm of axillary tail of left female breast
C50.621* Malignant neoplasm of axillary tail of right male breast
C50.622* Malignant neoplasm of axillary tail of left male breast
C50.811* Malignant neoplasm of overlapping sites of right female breast
C50.812* Malignant neoplasm of overlapping sites of left female breast
C50.821* Malignant neoplasm of overlapping sites of right male breast
C50.822* Malignant neoplasm of overlapping sites of left male breast
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C65.1* Malignant neoplasm of right renal pelvis
C65.2* Malignant neoplasm of left renal pelvis
C66.1* Malignant neoplasm of right ureter
C66.2* Malignant neoplasm of left ureter
C67.0* Malignant neoplasm of trigone of bladder
C67.1* Malignant neoplasm of dome of bladder
C67.2* Malignant neoplasm of lateral wall of bladder
C67.3* Malignant neoplasm of anterior wall of bladder
C67.4* Malignant neoplasm of posterior wall of bladder
C67.5* Malignant neoplasm of bladder neck
C67.6* Malignant neoplasm of ureteric orifice
C67.7* Malignant neoplasm of urachus
C67.8* Malignant neoplasm of overlapping sites of bladder
C67.9* Malignant neoplasm of bladder, unspecified
C68.0* Malignant neoplasm of urethra
C68.8* Malignant neoplasm of overlapping sites of urinary organs
C84.40 Peripheral T-cell lymphoma, not elsewhere classified, unspecified site
C84.48 Peripheral T-cell lymphoma, not elsewhere 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.

*Report ICD-10 code C50.011, C50.012, C50.021, C50.022, C50.111, C50.112, C50.121, C50.122, C50.211, C50.212, C50.221, C50.222, C50.311, C50.312, C50.321, C50.322, C50.411, C50.412, C50.421, C50.422, C50.511, C50.512, C50.521, C50.522, C50.611, C50.612, C50.621, C50.622, C50.811, C50.812, C50.821, or C50.822 with an ICD-10 code to identify anti-cancer therapy used (Z92.21, Z92.25, Z92.29, or Z92.3, as applicable).

*Report ICD-10 code C65.1, C65.2, C66.1, C66.2, C67.0, C67.1, C67.2, C67.3, C67.4, C67.5, C67.6, C67.7, C67.8, C67.9, C68.0, or C68.8 with an ICD-10 code to identify anti-cancer therapy used (Z92.21, Z92.25 and/or Z92.29, as applicable).

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
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

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
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

(1 Code)
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 code supports medical necessity and provides coverage for CPT code: 81401.

Group 15 Codes
Code Description
T36.5X5A Adverse effect of aminoglycosides, initial encounter

Group 16

(12 Codes)
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 codes support medical necessity and provide coverage for CPT code: 81406.

Group 16 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 17

(19 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 code supports medical necessity and provides coverage for CPT code: 81479 and Gene Test CYP2B6, and 0392U.

Group 17 Codes
Code Description
B20 Human immunodeficiency virus [HIV] disease
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
F32.81 Premenstrual dysphoric disorder
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

Group 18

(36 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 CYP4F2.

Group 18 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 19

(12 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 CACNA1S.

Group 19 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 20

(6 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 BCHE.

Group 20 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 21

(22 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 IFNL4.

Group 21 Codes
Code Description
B18.0* Chronic viral hepatitis B with delta-agent
B18.1* Chronic viral hepatitis B without delta-agent
B18.2* Chronic viral hepatitis C
C43.0* Malignant melanoma of lip
C43.111* Malignant melanoma of right upper eyelid, including canthus
C43.112* Malignant melanoma of right lower eyelid, including canthus
C43.121* Malignant melanoma of left upper eyelid, including canthus
C43.122* Malignant melanoma of left lower eyelid, including canthus
C43.21* Malignant melanoma of right ear and external auricular canal
C43.22* Malignant melanoma of left ear and external auricular canal
C43.31* Malignant melanoma of nose
C43.39* Malignant melanoma of other parts of face
C43.4* Malignant melanoma of scalp and neck
C43.51* Malignant melanoma of anal skin
C43.52* Malignant melanoma of skin of breast
C43.59* Malignant melanoma of other part of trunk
C43.61* Malignant melanoma of right upper limb, including shoulder
C43.62* Malignant melanoma of left upper limb, including shoulder
C43.71* Malignant melanoma of right lower limb, including hip
C43.72* Malignant melanoma of left lower limb, including hip
C43.8* Malignant melanoma of overlapping sites of skin
C43.9* Malignant melanoma of skin, unspecified
Group 21 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Dual diagnosis requirement: ICD-10 code B18.0, B18.1, or B18.2 must be reported with ICD-10 code K76.9 to indicate compensated liver disease.

*Dual diagnosis requirement: ICD-10 code C43.0, C43.111, C43.112, C43.121, C43.122, C43.21, C43.22, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.61, C43.62, C43.71, C43.72, C43.8 or C43.9 must be reported with ICD-10 code C77.9 to indicate nodal involvement.

Group 22

(2 Codes)
Group 22 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 22 Codes
Code Description
G70.80 Lambert-Eaton syndrome, unspecified
G70.81 Lambert-Eaton syndrome in disease classified elsewhere

Group 23

(70 Codes)
Group 23 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 23 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

Group 24

(7 Codes)
Group 24 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: 0193U.

Group 24 Codes
Code Description
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
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
N/A

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

Group 1

Group 1 Paragraph

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

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
99999 Not Applicable
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/01/2023 R8

Article revised and published on 07/20/2023 effective for dates of service on and after 07/01/2023 in response to the July HCPCS Quarterly Update. The following drugs have been added to Table 1 (CPIC): sertraline (CYP2B6/81479, 0392U) and venlafaxine and vortioxetine (CYP2D6/81226, 81418, 0392U).

The following CPT code has been added to the Article in the ‘CPT/HCPCS Codes’ section: 0392U in Code Groups 4 and 17.

The ‘ICD-10-CM Codes that Support Medical Necessity’ section has been revised to add ICD-10-CM codes as follows: Code Groups 2 and 3: F32.81; Code Group 4: F40.01, F40.11, F41.0, F41.1, F43.11, F43.12 and F60.5; and Code Group 17: F32.1, F32.2, F32.3, F32.4, F32.81, F32.9, F33.1, F33.2, F33.3, F33.41, F33.9, F40.01, F40.11, F41.0, F41.1, F43.11, F43.12 and F60.5.

04/27/2023 R7

Article revised and published on 04/27/2023 effective for dates of service on and after 01/01/2022 to remove CPT codes 0289U through 0294U from the CPT/HCPCS Code Group 25 that were erroneously added in January 2022.

03/09/2023 R6

Article revised and published on 03/09/2023 effective for dates of service on and after 10/26/2022 to update the article from CPIC and FDA sources. The following drugs have been added to Table 1 (CPIC): dapsone, methylene blue, nitrofurantoin, pegloticase, primaquine, tafenoquine (G6PD/81247) and nateglinide has been added to Table 2 (FDA) (CYP2C9/81227). The following ICD-10-CM codes were added to the ‘ICD-10-CM Codes that Support Medical Necessity’ section for Code Group 5: T38.3X5A and for Code Group 8: B51.0, B51.8, B51.9, D74.8, L70.0, M1A.0110, M1A.0111, M1A.0120, M1A.0121, M1A.0210, M1A.0211, M1A.0220, M1A.0221, M1A.0310, M1A.0311, M1A.0320, M1A.0321, M1A.0410, M1A.0411, M1A.0420, M1A.0421, M1A.0510, M1A.0511, M1A.0520, M1A.0521, M1A.0610, M1A.0611, M1A.0620, M1A.0621, M1A.0710, M1A.0711, M1A.0720, M1A.0721, M1A.08X0, M1A.08X1, M1A.09X0, M1A.09X1, M1A.1110, M1A.1111, M1A.1120, M1A.1121, M1A.1210, M1A.1211, M1A.1220, M1A.1221, M1A.1310, M1A.1311, M1A.1320, M1A.1321, M1A.1410, M1A.1411, M1A.1420, M1A.1421, M1A.1510, M1A.1511, M1A.1520, M1A.1521, M1A.1610, M1A.1611, M1A.1620, M1A.1621, M1A.1710, M1A.1711, M1A.1720, M1A.1721, M1A.18X0, M1A.18X1, M1A.19X0, M1A.19X1, M1A.2110, M1A.2111, M1A.2120, M1A.2121, M1A.2210, M1A.2211, M1A.2220, M1A.2221, M1A.2310, M1A.2311, M1A.2320, M1A.2321, M1A.2410, M1A.2411, M1A.2420, M1A.2421, M1A.2510, M1A.2511, M1A.2520, M1A.2521, M1A.2610, M1A.2611, M1A.2620, M1A.2621, M1A.2710, M1A.2711, M1A.2720, M1A.2721, M1A.28X0, M1A.28X1, M1A.29X0, M1A.29X1, M1A.3110, M1A.3111, M1A.3120, M1A.3121, M1A.3210, M1A.3211, M1A.3220, M1A.3221, M1A.3310, M1A.3311, M1A.3320, M1A.3321, M1A.3410, M1A.3411, M1A.3420, M1A.3421, M1A.3510, M1A.3511, M1A.3520, M1A.3521, M1A.3610, M1A.3611, M1A.3620, M1A.3621, M1A.3710, M1A.3711, M1A.3720, M1A.3721, M1A.38X0, M1A.38X1, M1A.39X0, M1A.39X1, M1A.4110, M1A.4111, M1A.4120, M1A.4121, M1A.4210, M1A.4211, M1A.4220, M1A.4221, M1A.4310, M1A.4311, M1A.4320, M1A.4321, M1A.4410, M1A.4411, M1A.4420, M1A.4421, M1A.4510, M1A.4511, M1A.4520, M1A.4521, M1A.4610, M1A.4611, M1A.4620, M1A.4621, M1A.4710, M1A.4711, M1A.4720, M1A.4721, M1A.48X0, M1A.48X1, M1A.49X0, M1A.49X1, N30.00* and N30.01* (with associated asterisk note). An asterisk note has also been added to ICD-10-CM Code Group 4 for ICD-10 code R11.2*.

01/01/2023 R5

Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. The ‘Coding Guidance’ section has been revised to add coding information for CPT code 81418. CPT code 81418 was added to Table 1 (CPIC) and Table 2 (FDA) for genes CYP2C19 and CYP2D6. Hydrocodone was also added to Table 1 (CPIC) for CYP2D6. Abrocitnib, mavacamten and belzutifan were added to Table 2 (FDA) for CYP2C19. The following CPT code has been added to the Article: 81418 in Code Groups 2, 3, and 4. The following ICD-10-CM codes were added to the ‘ICD-10-CM Codes that Support Medical Necessity’ section for Code Group 2: C25.4*, C64.1*, C64.2*, C65.1*, C65.2*, C66.1*, C66.2*, C67.0*, C67.1*, C67.2*, C67.3*, C67.4*, C67.5*, C67.6*, C67.7*, C67.8*, C68.0*, C68.1*, C68.8*, C7A.093*, D13.7*, D18.02*, D32.0*, D32.1*, D33.0*, D33.1*, D33.3*, D33.4*, D33.7*, I42.1, and L20.89 with associated asterisk note. Also, the Affected Subgroups in Table 2 was updated for pantoprazole, irinotecan and tramadol.

10/01/2022 R4

Article revised and published on 10/20/2022 effective for dates of service on and after 10/01/2022 to reflect the Annual ICD-10-CM Code Updates. For the following ICD-10-CM codes the code description has changed: C84.40 and C84.48 in Group 12.

02/07/2022 R3

Article revised and published on 08/04/2022 in response to an inquiry to update the article from CPIC and FDA sources. The following drugs and associated genes and CPT codes were added to Table 1 (CPIC): fosphenytoin, fluvastatin (CYP2C9/81227), fosphenytoin (HLA-B/81381, 81374), tramadol (CYP2D6/81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U), peginterferon alfa-2a, peginterferon alfa-2b (IFNL4/81479), pravastatin, atorvastatin, lovastatin, rosuvastatin, fluvastatin, pitavastatin (SLCO1B1/81328), gentamicin, amikacin, paromomycin, streptomycin, plazomicin, tobramycin (MT-RNR1/81401), and rosuvastatin (ABCG2/0193U). The following drugs were deleted from Table 1: aspirin, diclofenac, aceclofenac, indomethacin, lumiracoxib, metamizole, nabumetone, naproxen, tegafur, and ribavirin.

The following drugs and associated genes and CPT codes were added to Table 2 (FDA): voriconazole (CYP2C19/81225), fosphenytoin, meloxicam, phenytoin (CYP2C9/81227), oliceridine, pitolisant (CYP2D6/81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U), fosphenytoin, phenytoin (HLA-B/81381, 81374), and sacituzumab govitecan-hziy (UGT1A1/81350). The ‘Affected Subgroups’ column in Table 2 was revised for the following drugs: celecoxib (CYP2C9/81227) and flurbiprofen (CYP2C9/81227).

The ‘CPT/HCPCS Codes’ and ‘ICD-10-CM Codes that Support Medical Necessity’ sections were revised to add the following new groups effective for dates of service on and after 02/07/2022: ‘Group 15’ for CPT code 81401, ‘Group 21’ for CPT code 81479 and gene test IFNL4, and ‘Group 24’ for CPT code 0193U and all subsequent groups were renumbered accordingly in both sections.

The ‘ICD-10-CM Codes that Support Medical Necessity’ section has been revised to add ICD-10 codes as follows effective for dates of service on and after 12/12/2021: Group 2 for 81225 (B48.8* with an associated asterisk note), Group 3 for 81226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, and 0076U (G47.411 and G47.419), Group 5 for 81227 (E78.00, E78.01, E78.1, E78.2, I25.10, M06.8A, M19.09, M19.29, Z86.73, and Z86.79, Group 9 for 81283 (B18.0*, B18.1*, B18.2*, C43.0*, C43.111*, C43.112*, C43.121*, C43.122*, C43.21*, C43.22*, C43.31*, C43.39*, C43.4*, C43.51*, C43.52*, C43.59*, C43.61*, C43.62*, C43.71*, C43.72*, C43.8*, and C43.9* with associated asterisk notes), Group 11 for 81328 (E11.8*, E11.9*, I25.10, and associated asterisk note), and Group 12 for 81350 (C50.011*, C50.012*, C50.021*, C50.022*, C50.111*, C50.112*, C50.121*, C50.122*, C50.211*, C50.212*, C50.221*, C50.222*, C50.311*, C50.312*, C50.321*, C50.322*, C50.411*, C50.412*, C50.421*, C50.422*, C50.511*, C50.512*, C50.521*, C50.522*, C50.611*, C50.612*, C50.621*, C50.622*, C50.811*, C50.812*, C50.821*, C50.822*, C65.1*, C65.2*, C66.1*, C66.2*, C67.0*, C67.1*, C67.2*, C67.3*, C67.4*, C67.5*, C67.6*, C67.7*, C67.8*, C67.9*, C68.0*, and C68.8* with associated asterisk notes). Minor formatting changes have been made throughout the coding section.

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.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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SAD Process URL 2
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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