LCD Reference Article Billing and Coding Article

Billing and Coding: ProMark® Risk Score

A57034

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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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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57034
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: ProMark® Risk Score
Article Type
Billing and Coding
Original Effective Date
09/12/2019
Revision Effective Date
11/14/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §10 Reporting ICD Diagnosis and Procedure Codes

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

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

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: ProMark® Risk Score L36675.


To report a ProMark® assay service, please submit the following claim information:


• Select CPT® code 81479

• 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

• Select ICD-10-CM code C61

 

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

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph

c61

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

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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
11/14/2024 R8

Revision Effective: 11/14/2024

Revision Explanation: Annual review, no changes.

12/07/2023 R7

Revision Effective: 12/07/2023

Revision Explanation: Annual review, no changes.

11/16/2023 R6

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.

11/24/2022 R5

Revision Effective: 12/30/2021

Revision Explanation: Annual review, no changes 

12/23/2021 R4

Revision Effective: 12/30/2021

Revision Explanation: Under Article Title added registered mark to ProMark and revised title to ProMark® Risk Score. Under CMS National Coverage Policy added regulation CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories. Under Article Text revised title to ProMark® Risk Score. Formatting, punctuation and typographical errors were corrected throughout the article. ProMark® was inserted throughout the article were applicable.

11/14/2019 R3

Revision Effective: n/a

Revision Explanation: Annual review, no changes were made.

11/14/2019 R2

Revision Effective: 11/14/2019

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. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related MolDX: ProMark Risk Score L36675 LCD and placed in this article.

09/19/2019 R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

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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
L36675 - ProMark® Risk Score
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
11/08/2024 11/14/2024 - N/A Currently in Effect You are here
11/29/2023 12/07/2023 - 11/13/2024 Superseded View
11/10/2023 11/16/2023 - 12/06/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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