LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268)

A54832

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Source Article ID
N/A
Article ID
A54832
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268)
Article Type
Billing and Coding
Original Effective Date
01/07/2016
Revision Effective Date
04/04/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5 Jurisdiction of Laboratory Claims, §60.1.1 Independent Laboratory Specimen Drawing, §60.2 Travel Allowance

Article Guidance

Article Text

Please note that CPT® codes 81265 and 81266 describe services performed for recipient/donor testing and twin zygosity. Tests indicated for recipient/donor testing will be considered for payment and tests for twin zygosity will be denied as a statutorily excluded service. The following instructions outline the correct reporting of recipient/donor testing for transplant services.

Chimerism analysis to identify appropriate donors and monitor engraftment success or disease reoccurrence is a covered Medicare service.

    • Code 81265 should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.
    • Code 81266, when used in bone marrow transplants to report an additional double-cord blood sample, is a covered service.
    • Code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, an additional 81265 should NOT be submitted in addition to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.

Note: Code 81267 should be reported for the findings of the pre and post-transplant comparison.

 

    • Code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.

    MolDX would not expect to see a claim for 81265 pre-transplant and an additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant and an additional claim for 81268.

    EXCEPTIONS: Although the initial chimerism testing, code 81265, for engraftment is usually limited to once in a lifetime, MolDX recognizes special circumstances may require an additional service and will consider approval on a case-by-case basis through the appeal process.

    To report a Molecular Diagnostic Test service, please submit the following claim information:

    • Select appropriate CPT® code
    • Enter 1 unit of service (UOS)
    • Enter the appropriate DEX Z-Code® identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types:
      • Loop 2400 or SV101-7 for the 5010A1 837P
      • Box 19 for paper claim
    • Enter the appropriate DEX Z-Code® identifier adjacent to the CPT® code in the comment/narrative field for the following Part A claim field/types:
      • Line SV202-7 for 837I electronic claim
      • Block 80 for the UB04 claim form

    NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.

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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.

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    Revision History Information

    Revision History Date Revision History Number Revision History Explanation
    04/04/2024 R5

    Under Article Title revised to read Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268). Under CMS National Coverage Policy revised 3rd section heading. Under Article Text revised 7th and 10th bullets to remove “DEX Z-Code™” and replaced with “DEX Z-Code®”. Added “NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line”. Formatting was corrected throughout the article. This revision is effective 4/4/2024.

    Under CPT/HCPCS Group 1: Codes added 81479. This is effective 3/5/2024.

    03/17/2022 R4

    Under CMS National Coverage Policy added regulations Title XVIII of the Social Security Act, §1833(e) Prohibits Medicare payment for any claim which lacks the necessary information to process the claim, CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories, and CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5 Jurisdiction of Laboratory Claims, §60.1.2 Independent Laboratory Specimen Drawing, §60.2. Travel Allowance. Under Article Text deleted the verbiage, “Laboratories are encouraged to register tests based on the use of the test” and “Through the MolDX identification process”. Revised third sentence to read, “Tests indicated for recipient/donor testing will be considered for payment and tests for twin zygosity will be denied as a statutorily excluded service.” and added verbiage regarding instructions on how to submit claims information. Formatting, punctuation, and typographical errors were corrected throughout the article.

    12/12/2019 R3

    This revision is to add Bill Type code 023X which was inadvertently left off.

    11/21/2019 R2

    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. Under Article Title changed title from Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (codes 81265-81268) Coding and Billing Guidelines to Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268). CPT® was inserted throughout the article where appropriate.

    02/26/2018 R1 The Jurisdiction "J" Part A and Part B Contracts for Alabama (10111/10112), Georgia (10211/10212) and Tennessee (10311/10312) are now being serviced by Palmetto GBA. Effective 02/26/18, these 6 contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 6 Part A and B contract numbers) have been completed in this revision.
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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
    L35025 - MolDX: Molecular Diagnostic Tests (MDT)
    Related National Coverage Documents
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    Updated On Effective Dates Status
    03/28/2024 04/04/2024 - N/A Currently in Effect You are here
    03/09/2022 03/17/2022 - 04/03/2024 Superseded View
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