LCD Reference Article Billing and Coding Article

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

A55621

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General Information

Source Article ID
N/A
Article ID
A55621
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
08/15/2017
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 1 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.

  • Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
  • Select the 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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Coding Information

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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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Coding Table Information

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/04/2024 R6

Posted 04/25/2024: 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.

03/28/2024 R5

Posted 03/28/2024- No changes made to coverage. Review complete 02/15/2024.

03/31/2022 R4

Posted 03/31/2022- 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. Review completed 02/28/2022.

11/25/2021 R3

11/25/2021-Review completed 10/12/2021; no changes made.

11/01/2019 R2

Content moved to the new template. Review completed 11/01/2019.

06/01/2018 R1

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

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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 2
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Updated On Effective Dates Status
04/16/2024 04/04/2024 - N/A Currently in Effect You are here
03/20/2024 03/28/2024 - 04/03/2024 Superseded View
03/22/2022 03/31/2022 - 03/27/2024 Superseded View
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