LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)

A57772

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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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General Information

Source Article ID
N/A
Article ID
A57772
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
Article Type
Billing and Coding
Original Effective Date
11/01/2019
Revision Effective Date
07/01/2024
Revision Ending Date
N/A
Retirement Date
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CMS National Coverage Policy

Title XVIII of the Social Security Act (SSA) §1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1 Clinical Laboratory Services.

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.

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

Article Guidance

Article Text

The information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L36807.

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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Coding Information

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
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Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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ICD-10-PCS 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.

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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

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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
07/01/2024 R20

Posted 08/01/2024: Under CPT/HCPCS Codes Group 1: Codes deleted 0204U. Added 0020M, 0452U, 0453U, 0454U, 0456U, 0460U, 0461U, 0463U, 0464U, 0465U, 0466U, 0467U, 0469U, 0470U, 0471U, 0473U, 0474U, and 0475U. Under CPT/HCPCS Codes Group 2: Codes deleted 0353U. Added 0455U. This revision is due to the 2024 Q3 CPT/HCPCS Code Update and is effective 7/1/2024.

04/01/2024 R19

Posted 04/25/2024: Under CPT/HCPCS Codes Group 1: Codes deleted 0416U. Added 0439U, 0440U, 0444U, 0448U, and 0449U. This revision is due to the 2024 Q2 CPT/HCPCS Code Update and is effective 4/1/2024.

Under CPT/HCPCS Codes Group 1: Codes added 0112U. This revision is effective 4/1/2024.

01/01/2024 R18

Posted 02/01/2024: Under CPT/HCPCS Codes Group 1: Codes the description was revised for 0356U, 81171, 81172, 81243, 81244, 81445, 81449, 81450, 81451, 81455, and 81456. Added 81457, 81458, 81459, 81462, 81463, 81464, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0428U, 0433U, 0434U, 0437U, and 0438U. This revision is due to the 2024 Annual/Q1 CPT/HCPCS Code Update and is effective 1/1/2024.

Under CPT/HCPCS Codes Group 1: Codes deleted 0228U. This revision is effective 1/1/2024.

Under Article Text 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”. Under CPT/HCPCS Group 1: Codes added 81599, 0253U, and 0254U. Under CPT/HCPCS Group 2: Paragraph revised first sentence to read “For DNA/RNA based testing that use CPT® code 87999 a Z-code is required for claims submission”. Under CPT/HCPCS Group 2: Codes deleted 81599. This revision is effective 1/1/2024.

10/01/2023 R17

Posted 10/26/2023: Under CPT/HCPCS Codes Group 1: Codes the description was revised for 0258U, 0269U, 0271U, 0272U, 0274U, 0277U, 0278U, and 0362U. Added 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0416U, 0417U, and 0419U. Deleted 0386U and 0397U. Under CPT/HCPCS Codes Group 2: Codes added 0402U. This revision is due to the 2023 Q4 CPT/HCPCS Code Update and is effective on 10/1/2023.

Under Article Text revised the 3rd and 6th bullets to remove “DEX Z-Code™” and replaced with “DEX Z-Code®”. This revision is effective on 10/1/2023.

07/01/2023 R16

Posted 07/27/2023: Under CMS National Coverage Policy updated section heading. This revision is effective on 7/1/2023.

Under CPT/HCPCS Codes Group 1: Codes added 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0397U, 0398U, 0400U, and 0401U. This revision is due to the 2023 Q3 CPT/HCPCS Code Update and is effective on 7/1/2023.

04/01/2023 R15

Posted 04/27/2023: Under CPT/HCPCS Codes Group 1: Codes added 0364U, 0368U, 0369U, 0370U, 0371U, 0372U, 0373U, 0374U, 0378U, 0379U, 0380U, and 0386U. The description was revised for 0022U. This revision is due to the 2023 Q2 CPT/HCPCS Code Update and is effective on April 1, 2023.

01/01/2023 R14

Posted 01/26/2023: Under CPT/HCPCS Codes Group 1: Codes, added 81418, 81441, 81449, 81451, 81456, 0355U, 0356U, 0362U, and 0363U. The description was revised for 81330, 81445, 81450, 81455, 0017M, and 0069U. Under CPT/HCPCS Codes Group 2: Codes, the description was revised for 87999. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is effective on January 1, 2023.

10/01/2022 R13

Posted 10/27/2022: Under CPT/HCPCS Codes Group 1: Codes added 0318U. This revision is due to the Q2 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 04/01/2022.

Under CPT/HCPCS Codes Group 1: Codes added 0327U. This revision is due to the Q3 2022 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 07/01/2022.

Under CPT/HCPCS Codes Group 1: Codes added 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, deleted 0012U, 0013U, 0014U, 0056U, and the description was revised for 0229U, 0262U, 0276U, 0296U, 0319U. Under CPT/HCPCS Codes Group 2: Codes added 0352U, 0353U. This revision is due to the Q4 2022 CPT/HCPCS Code Update and is effective for dates of service on or after 10/01/2022.

Under CPT/HCPCS Codes Group 2: Paragraph revised the first and second sentence. Under CPT/HCPCS Codes Group 2: Codes added 81513, 81514, 87154, 87483, 87505, 87506, 87507, 87631, 87632, 87633, 87636, 87637, 0115U, 0202U, 0223U, 0225U, 0240U, 0241U. This revision is retroactive effective for dates of service on or after 04/17/2022.

07/01/2022 R12

Posted 09/01/2022 Under CPT/HCPCS Codes Group 1: Codes the description was revised for 0016M, 0229U, and 0306U. The following codes were added 0323U, 0326U, 0329U, 0330U, and 0331U. This revision is due to the Q3 2022 CPT/HCPCS Code Update and is effective on 07/01/2022. Review completed 07/25/2022.

05/17/2022 R11

Posted 05/26/2022-Under CPT/HCPCS Codes Group1: Codes added 0306U, 0307U, 0313U, 0314U, 0315U, 0319U, 0320U and revised the description for 0022U. This revision is due to the Q2 CPT/HCPCS Code Update and is effective for dates of service on or after 04/01/2022.

Under CPT/HCPCS Codes Group 2: Paragraph added the verbiage, “However, for molecular microbiology tests using codes 87800 and 87801, a Z-code is only required for non-FDA-approved/cleared services/tests.”

Under CPT/HCPCS Codes Group2: added codes 87800 and 87801. This revision is effective on 05/17/2022. Review completed 05/05/2022.

04/17/2022 R10

Posted 04/28/2022-Moved CPT 81599 from CPT/HCPCS Codes Group 1 to CPT/HCPCS Codes Group 2. Added CPT 87999 to Group 2 codes and added “The following CPT codes require a Z-code if the testing is molecular (DNA/RNA) based” to Group 2 Paragraph.

01/01/2022 R9

01/27/2022-Under CPT/HCPCS Codes Group 1: Paragraph added the verbiage “The codes listed below fall within scope of the associated policy but do not automatically imply coverage. Under CPT/HCPCS Codes Group 1: Codes added 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0297U, 0298U, 0299U, 0300U, 81349, and 81523. Deleted 0208U. This revision is effective 01/01/2022.

01/01/2022 R8

12/30/2021-CPT/HCPCs code update: desc change for 0016M, 0017M, 0090U, 0154U, 0155U, 0177U, 0180U, 0193U, 0200U, 0205U, 0216U, 0221U, 0244U, 0258U, 0262U, 0265U, 0266U, 0276U, 81194, 81228, 81229.

10/01/2021 R7

11/25/2021- Under CPT/HCPCS Codes Group 1: Codes added 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U and deleted 0168U. This revision is due to the Q4 2021 CPT®/HCPCS Code Update and is effective for dates of service on or after 10/1/2021.Review completed 10/20/2021.

07/01/2021 R6

08/26/2021-Under CPT/HCPCS Group 1: Codes added 0016M. This revision is due to coding that is applicable to the MolDX program and is retroactive effective for dates of service on or after 01/01/2021.

Under CPT/HCPCS Codes Group 1: Codes added 0250U. This revision is due to the Q3 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 07/01/2021.

04/01/2021 R5

05/27/2021- Under CPT/HCPCS Group 1: Codes added 0017M and deleted 0105U. This revision is due to coding that is applicable to the MolDX program and is retroactive effective for dates of service on or after 1/1/2021.

Under CPT/HCPCS Group 1: Codes added 0242U, 0244U, 0245U, and 0246U. This revision is due to the Q2 2021 CPT/HCPCS Code Update and is effective for dates of service on or after 4/1/2021.

01/01/2021 R4

02/25/2021-Under CPT/HCPCS Codes Group 1: Codes added 81374, 81377, 81381, 81383, 0069U, 0133U, 0168U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U 0201U, 0203U, 0204U, 0205U, 0208U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0221U, and 0222U and deleted 81490, 81500, 81503, 81506, 81508, 81509, 81510, 81511, 81512, 81535, 81536, 81538, 81539, 84999, 85999, 86152, 86153, 86849, 87999, 0003U, 0009U, 0021U, 0024U, 0039U, 0053U, 0054U, 0058U, 0059U, 0062U, 0067U, 0068U, 0080U, 0083U, 0092U, 0107U, and 0108U. Under CPT/HCPCS Codes Group 2: Codes moved 81401, 81403, 81406, 81407, 81412 to CPT/HCPCS Codes Group 1: Codes.
This revision is due to coding that is applicable to the MolDX program and is retroactive effective for dates of service on or after 1/1/2021.

Under CPT/HCPCS Codes Group 1: Codes added 81168, 81191, 81192, 81193, 81194, 81278, 81279, 81338, 81339, 81347, 81348, 81351, 81352, 81353, 81357, 81360, 81419, 81529, 81546, 81554, 0228U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, deleted 81545.
This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/01/2020 R3

11/26/2020- Under CPT/HCPCS codes Group 1: 0154U code description was revised due to Q4 CPT/HCPCs code updates.

04/01/2020 R2

05/28/2020-Under CPT/HCPCS Codes Group 1: Codes- description change for CPT codes 0154U & 0155U. Formatting, & punctuation corrected under CMS National Coverage Policy section. This revision is due to the Q2 2020 CPT/HCPCS code update. Review completed 04/28/2020.

01/01/2020 R1

12/26/2019- Under CPT/HCPCS Codes Group 1: Codes added CPT® codes 87999, 0045U-0050U, 0053U-0060U, 0062U, 0067U, 0068U, 0070U-0076U, 0078U-0080U, 0083U, 0105U, 0107U, 0108U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U-0132U, and 0134U-0138U. CPT® codes 81370-81383, 81596, 88120, 88121, 0002M, 0003M, 0002U, 0006U-0008U, 0010U, 0011U, 0025U, 0035U, 0038U, 0041U-0044U, 0086U, 0093U, 0095U-0100U were deleted. These additions and deletions are due to coding that is applicable to the MolDX program.

Added 0084U-0104U due to 3rd quarter 2019 CPT/HCPCS code updates-effective 07/01/2019. 0104U was deleted due to 4th quarter code update & 0008U, 81404 and 81407 descriptions changed –effective 10/01/20119. Moved CPT codes 81401, 81403, 81406, 81407 and 81412 from Group 1 to Group 2 CPT/HCPCS code section and added “CPT codes that are also referenced in other articles” to the Group 2 paragraph.

Effective 01/01/2020: Annual CPT®/HCPCS Code Update: Under CPT/HCPCS Codes Group 1: Codes added CPT® codes 81277, 81307, 81308, 81309, 81522, 81542, 81552, and code range 0153U-0162U. CPT® codes 0009M and 0085U were deleted. The code descriptions were revised for CPT® codes 81350, 0101U, 0102U, and 0103U.

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