RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: MECP2 Genetic Testing

A55189

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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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Source Article ID
N/A
Article ID
A55189
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: MECP2 Genetic Testing
Article Type
Billing and Coding
Original Effective Date
02/16/2017
Revision Effective Date
11/30/2023
Revision Ending Date
05/30/2024
Retirement Date
05/30/2024

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Article Text

Effective for dates of service on and after February 19, 2013.

Mutations found in methyl CpG binding protein 2(MECP2) are associated with Rett syndrome. In classic Rett syndrome, suspected cases are identified through specific clinical criteria in female children ages 1-5. Genetic testing is used to confirm the clinical findings. Since 99% of classic cases result in a single random mutation, genetic testing is not useful to screen carriers. Therefore, the MolDX Team has determined that MECP2 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, MolDX will also deny panels of tests that include a MECP2 gene test as a statutorily excluded service.
To receive a MECP2 test denial, please submit the following claim information:

  • Appropriate CPT codes:
    • 81302- MECP2, full gene sequence
    • 81303- MECP2, known familial variant
    • 81304- MECP2, duplication/deletion variants
    • 81470 - X-linked intellectual disability genomic sequence analysis panel
    • 81471- X-linked intellectual disability genomic sequence analysis panel duplication/deletion
    • 81479- MECP2, panel 
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
    • For a voluntary issued ABN, append with GX HCPCS modifier
    • To indicate a statutorily excluded service, append with a GY HCPCS modifier 
  • Select the appropriate diagnosis for the patient 
  • Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
  • 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 

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Coding Information

Bill Type Codes

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CPT/HCPCS Modifiers

Group 1

(2 Codes)
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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

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

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ICD-10-PCS Codes

Group 1

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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.

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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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Other Coding Information

Group 1

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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
05/30/2024 R7

Posted 05/30/2024: This article is being retired because it is not supported by a Local Coverage Determination (LCD) and does not comply with current 21st Century Cures requirements.

11/30/2023 R6

Posted 11/30/2023: Biannual review completed with no change in coverage. No changes were made to the article.

11/25/2021 R5

11/25/2021-Review completed 10/18/2021; no changes made.

11/01/2019 R4

This article is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual. Under Article Title changed the title from “MolDX: MECP2 Genetic Testing Coding and Billing Guidelines” to “Billing and Coding: MolDX: MECP2 Genetic Testing”. Under Article Text removed the last paragraph related to a reference. Under CPT/HCPCS Modifiers Group 1: Codes added modifiers GX and GY. Review completed 11/18/2019.

01/01/2019 R3

02/01/2019-Code update: added 81470 & 81471.

06/01/2018 R2

06/01/2018-Annual review completed 05/03/2018.

07/01/2017 R1

07/01/2017- Annual review completed 06/09/2017; Updated billing instructions, added Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information & added Part A billing instructions and updated Part B instructions.

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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
L36807 - 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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Public Versions
Updated On Effective Dates Status
05/30/2024 11/30/2023 - 05/30/2024 Retired You are here
11/20/2023 11/30/2023 - N/A Superseded View
11/16/2021 11/25/2021 - 11/29/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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