LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: L1CAM Gene Sequencing Guidelines

A54274

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Draft Article
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
A54274
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: L1CAM Gene Sequencing Guidelines
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
11/22/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Article Guidance

Article Text

Effective for dates of service on and after January 29, 2013

L1 syndrome refers to multiple disorders including X-linked hydrocephalus with aqueduct of Sylvius (HSAS) stenosis, MASA syndrome (Mental retardation, Aphasia, Spastic paraplegia, Adducted thumbs), SPG1 (X-linked complicated hereditary spastic paraplegia type 1), and X-linked complicated corpus callosum agenesis. Because there are many potential underlying causes for congenital hydrocephalus, including syndromic and nonsyndromic cases, recurrence risk and implications for family members is based upon underlying etiology. Genetic testing of the L1CAM gene is used to confirm a clinical diagnosis and provide recurrence risk. Therefore, the MolDX Team has determined L1CAM full gene sequencing is a statutorily excluded test.

To receive a L1CAM gene sequencing service denial, please submit the following claim information:

  • CPT code 81407-L1CAM
  • CPT code 81470- X-linked intellectual disability genomic sequence analysis panel
  • CPT code 81471- X-linked intellectual disability genomic sequence analysis panel duplication / deletion
    • For a voluntary issued ABN, append with GX modifier
    • To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
  • Enter DEX Z-Code™ identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:
    • Loop 2400 or SV101-7 for the 5010A1 837P
    • Box 19 for paper claim
  • Enter DEX Z-Code™ identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:
    • Line SV202-7 for 837I electronic claim
    • Block 80 for the UB04 claim form

 

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

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

Group 1

Group 1 Paragraph

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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Revenue Codes

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

Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

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

Revision History Date Revision History Number Revision History Explanation
11/22/2023 R13

Revision Effective: 11/22/2023

Revision Explanation: Updated LCD Reference Article section.

11/14/2019 R12

Revision Effective: N/A
Revision Explanation:This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Added “SSA §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” to the CMS National Coverage Policy section of this article. Under Article Title title was changed to “Billing and Coding: MolDX: L1CAM Gene Sequencing”. Under CPT/HCPCS Codes created Group 2: Paragraph and added verbiage “HCPCS codes that are also referenced in other articles”.Created Group 2: Codes and moved CPT® 81407 from Group 1: Codes to Group 2: Codes. Under the CPT/HCPCS Modifiers section Group 1: Codes modifiers GY and GX were added.

This revision is effective 11/14/19.

 

The description of CPT® code 81407 has been changed.

The revision for the code descriptor is due to the Quarter 4 CPT®/HCPCS updates and was effective on 10/1/2019.

10/03/2019 R11

Revision Effective: N/A
Revision Explanation: Annual review no changes made.

10/03/2019 R10

Revision Effective date: 10/03/2019
Revision Explanation: Converted article into new billing and coding article format.

01/01/2019 R9

Revision Effective date: 01/01/2019
Revision Explanation: During annual HCPCS update new codes 81470 and 81471 were added to this article.

07/20/2017 R8

Revision Effective date: N/A
Revision Explanation: Annual review no changes made.

10/01/2015 R7

Revision Effective date: N/A
Revision Explanation: Annual review no changes made

07/20/2017 R6

Revision Effective date: 07/20/2017
Revision Explanation: Added DEX Z-Code identifier information

10/01/2015 R5 Revision Effective date: N/A
Revision Explanation: Annual review no changes made.
07/14/2016 R4 Revision Effective: 07/14/2016
Revision Explanation: Corrected the CPT code that should be used for submitting claims for this test from 81479 to 81407.
10/01/2015 R3 Revision Effective: N/A
Revision Explanation: Annual review no changes made.
10/01/2015 R2 R1
Revision Effective:10/01/2015
Revision Explanation: Changed MoPath to MolDX .
10/01/2015 R1 Revision Effective: N/A
Revision Explanation: Added Part A loop information.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L36021 - MolDX: Molecular Diagnostic Tests (MDT)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/14/2023 11/22/2023 - N/A Currently in Effect You are here
01/13/2020 11/14/2019 - 11/21/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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