RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: NSD1 Gene Tests

A55198

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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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Article Information

General Information

Source Article ID
N/A
Article ID
A55198
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: NSD1 Gene Tests
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

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

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CMS National Coverage Policy

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Article Guidance

Article Text

Effective for dates of service on and after June 26, 2013.

NSD1 gene testing may be performed during the diagnosis of Sotos Syndrome. Since testing is limited to reproductive risk assessment, the MolDX Team has determined NSD1 gene testing is a statutorily excluded service. MolDX will also deny tests that include one or more of NSD1 analysis reported with CPT code 81479 as statutorily excluded tests.

To receive a NSD1 analysis service denial, please submit the following claim information:

  • Select appropriate CPT code according to genetic material test
    • Code 81405 for NSD1 duplication/deletion
    • Code 81406 for NSD1 gene sequencing
    • Code 81479 for combinations of NSD1 analysis
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    • 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 modifier
  • 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 

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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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

NA

Group 1 Codes

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

Group 1

Group 1 Paragraph

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Group 1 Codes

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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
N/A N/A
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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 R9

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 R8

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

11/25/2021 R7

11/25/2021-Review completed 10/26/2021; no changes made.

11/01/2019 R6

Under Article Text deleted the statement “Select the appropriate diagnosis for the patient” & the last sentence related to a reference. Moved CPT 81406 from CPT/HCPCS Codes Group 1: to Group 2. Under CPT/HCPCS Codes Group 2: Paragraph added verbiage, “CPT codes that are also referenced in other articles”. Added modifiers to the modifier table. Content moved to the new template & review completed 11/18/2019.

01/01/2019 R5

02/01/2019-Code update: removing 81403.

01/01/2019 R4

01/01/2019- Code updates: 81403 & 81405 long description changes.

08/01/2018 R3

08/01/2018-Annual review completed 07/02/2018.

01/01/2018 R2

01/01/2018- Code update-81403, 81405, 81406 description change.

08/01/2017 R1

08/01/2017- Annual review completed 07/06/2017; 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
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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