LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers

A59004

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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
A59004
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers
Article Type
Billing and Coding
Original Effective Date
12/26/2021
Revision Effective Date
10/01/2024
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.

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38835.

A Minimal Residual Disease (MRD) test, as defined in the related policy, is a service that may include multiple components and/or multiple timepoints (i.e., serial assays). Testing schedules are set based on the validity established for the individual test comprising the service. Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the policy. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the policy.

The following tests have met the criteria for coverage under the policy

Manufacturer Test Indicated Uses and Limitations
Adaptive Biotechnologies

ClonoSeq®

Note: An episode of testing typically requires a baseline assay and multiple follow-up assays.

Acute lymphoblastic leukemia (ALL), Multiple myeloma (MM), and Chronic lymphocytic leukemia (CLL) and Diffuse Large B-Cell Lymphoma (DLBCL). Refer to CPT/HCPCS Group 2 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 2 Codes.

This Table will be updated to reflect revisions and additions of newly covered tests.

Coverage of CLONOSEQ® for other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.

Additional process requirements for coverage and billing:
MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.

Single-gene PCR tests:
For patients with or without cancer (as defined in the policy), established standard-of-care MRD tests using single-gene PCR (i.e., BCR-ABL1) may be billed on an individual basis according to testing schedules outlined in national (i.e., NCCN) or society guidelines, with 1 UOS for each date of service. Refer to CPT/HCPCS Group 3 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 3 Codes.

  • Regarding single-gene and panel testing of genes – Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A57880 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A57772.

Other tests (i.e., ClonoSeq®):

For patients with cancer, the unit of service for this type of test is 1. Billing should occur at the start of the episode of testing. Regarding the use of NGS-based MRD tests (i.e., ClonoSeq®) in patients with cancer. The service may be performed once per patient per cancer diagnosis, unless there is clinical evidence of a priori change in genetic content.

For patients without cancer (as defined in the policy), a second kind of test may exist wherein a single timepoint may constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate ‘Personal history of cancer’ ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.

Refer to additional instructions outlined in the relevant Group sections below.

Regarding NGS panels:

To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPT® 81479 and one (1) UOS with the assigned DEX Z-Code®.

Billing instructions:

Billing requires a Z-identifier code to be submitted with the claim. All tests must be registered with the DEX™ Diagnostic Exchange application.

To report an episode of testing, please submit the following claim information:

  • Select the appropriate CPT® code. If no specific CPT code exists for the test submitted, bill with the NOC 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 5010A 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 the appropriate ICD-10-CM code

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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CPT/HCPCS Codes

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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

(513 Codes)
Group 1 Paragraph

The following ICD-10 codes can be used with MRD tests for the purpose of diagnosing disease progression, recurrence, or relapse.

Group 1 Codes
Code Description
C81.00 - C81.09 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site - Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites
C81.0A Nodular lymphocyte predominant Hodgkin lymphoma, in remission
C81.10 - C81.19 Nodular sclerosis Hodgkin lymphoma, unspecified site - Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites
C81.1A Nodular sclerosis Hodgkin lymphoma, in remission
C81.20 - C81.29 Mixed cellularity Hodgkin lymphoma, unspecified site - Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites
C81.2A Mixed cellularity Hodgkin lymphoma, in remission
C81.30 - C81.39 Lymphocyte depleted Hodgkin lymphoma, unspecified site - Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites
C81.3A Lymphocyte depleted Hodgkin lymphoma, in remission
C81.40 - C81.49 Lymphocyte-rich Hodgkin lymphoma, unspecified site - Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites
C81.4A Lymphocyte-rich Hodgkin lymphoma, in remission
C81.70 - C81.79 Other Hodgkin lymphoma, unspecified site - Other Hodgkin lymphoma, extranodal and solid organ sites
C81.7A Other Hodgkin lymphoma, in remission
C81.90 - C81.99 Hodgkin lymphoma, unspecified, unspecified site - Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C81.9A Hodgkin lymphoma, unspecified, in remission
C82.00 - C82.09 Follicular lymphoma grade I, unspecified site - Follicular lymphoma grade I, extranodal and solid organ sites
C82.0A Follicular lymphoma grade I, in remission
C82.10 - C82.19 Follicular lymphoma grade II, unspecified site - Follicular lymphoma grade II, extranodal and solid organ sites
C82.1A Follicular lymphoma grade II, in remission
C82.20 - C82.29 Follicular lymphoma grade III, unspecified, unspecified site - Follicular lymphoma grade III, unspecified, extranodal and solid organ sites
C82.2A Follicular lymphoma grade III, unspecified, in remission
C82.30 - C82.39 Follicular lymphoma grade IIIa, unspecified site - Follicular lymphoma grade IIIa, extranodal and solid organ sites
C82.3A Follicular lymphoma grade IIIa, in remission
C82.40 - C82.49 Follicular lymphoma grade IIIb, unspecified site - Follicular lymphoma grade IIIb, extranodal and solid organ sites
C82.4A Follicular lymphoma grade IIIb, in remission
C82.50 - C82.59 Diffuse follicle center lymphoma, unspecified site - Diffuse follicle center lymphoma, extranodal and solid organ sites
C82.5A Diffuse follicle center lymphoma, in remission
C82.60 - C82.69 Cutaneous follicle center lymphoma, unspecified site - Cutaneous follicle center lymphoma, extranodal and solid organ sites
C82.6A Cutaneous follicle center lymphoma, in remission
C82.80 - C82.89 Other types of follicular lymphoma, unspecified site - Other types of follicular lymphoma, extranodal and solid organ sites
C82.8A Other types of follicular lymphoma, in remission
C82.90 - C82.99 Follicular lymphoma, unspecified, unspecified site - Follicular lymphoma, unspecified, extranodal and solid organ sites
C82.9A Follicular lymphoma, unspecified, in remission
C83.00 - C83.09 Small cell B-cell lymphoma, unspecified site - Small cell B-cell lymphoma, extranodal and solid organ sites
C83.0A Small cell B-cell lymphoma, in remission
C83.10 - C83.19 Mantle cell lymphoma, unspecified site - Mantle cell lymphoma, extranodal and solid organ sites
C83.1A Mantle cell lymphoma, in remission
C83.30 - C83.38 Diffuse large B-cell lymphoma, unspecified site - Diffuse large B-cell lymphoma, lymph nodes of multiple sites
C83.390 Primary central nervous system lymphoma
C83.398 Diffuse large B-cell lymphoma of other extranodal and solid organ sites
C83.3A Diffuse large B-cell lymphoma, in remission
C83.50 - C83.59 Lymphoblastic (diffuse) lymphoma, unspecified site - Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites
C83.5A Lymphoblastic (diffuse) lymphoma, in remission
C83.70 - C83.79 Burkitt lymphoma, unspecified site - Burkitt lymphoma, extranodal and solid organ sites
C83.7A Burkitt lymphoma, in remission
C83.80 - C83.89 Other non-follicular lymphoma, unspecified site - Other non-follicular lymphoma, extranodal and solid organ sites
C83.8A Other non-follicular lymphoma, in remission
C83.90 - C83.99 Non-follicular (diffuse) lymphoma, unspecified, unspecified site - Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites
C83.9A Non-follicular (diffuse) lymphoma, unspecified, in remission
C84.00 - C84.09 Mycosis fungoides, unspecified site - Mycosis fungoides, extranodal and solid organ sites
C84.0A Mycosis fungoides, in remission
C84.10 - C84.19 Sezary disease, unspecified site - Sezary disease, extranodal and solid organ sites
C84.1A Sezary disease, in remission
C84.40 - C84.49 Peripheral T-cell lymphoma, not elsewhere classified, unspecified site - Peripheral T-cell lymphoma, not elsewhere classified, extranodal and solid organ sites
C84.4A Peripheral T-cell lymphoma, not elsewhere classified, in remission
C84.60 - C84.68 Anaplastic large cell lymphoma, ALK-positive, unspecified site - Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites
C84.6A Anaplastic large cell lymphoma, ALK-positive, in remission
C84.7A Anaplastic large cell lymphoma, ALK-negative, breast
C84.7B Anaplastic large cell lymphoma, ALK-negative, in remission
C85.10 - C85.19 Unspecified B-cell lymphoma, unspecified site - Unspecified B-cell lymphoma, extranodal and solid organ sites
C85.1A Unspecified B-cell lymphoma, in remission
C85.20 - C85.29 Mediastinal (thymic) large B-cell lymphoma, unspecified site - Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites
C85.2A Mediastinal (thymic) large B-cell lymphoma, in remission
C85.80 - C85.89 Other specified types of non-Hodgkin lymphoma, unspecified site - Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites
C85.8A Other specified types of non-Hodgkin lymphoma, in remission
C85.90 - C85.99 Non-Hodgkin lymphoma, unspecified, unspecified site - Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C85.9A Non-Hodgkin lymphoma, unspecified, in remission
C86.00 Extranodal NK/T-cell lymphoma, nasal type not having achieved remission
C86.01 Extranodal NK/T-cell lymphoma, nasal type, in remission
C86.10 Hepatosplenic T-cell lymphoma not having achieved remission
C86.11 Hepatosplenic T-cell lymphoma, in remission
C86.20 Enteropathy-type (intestinal) T-cell lymphoma not having achieved remission
C86.21 Enteropathy-type (intestinal) T-cell lymphoma, in remission
C86.30 Subcutaneous panniculitis-like T-cell lymphoma not having achieved remission
C86.31 Subcutaneous panniculitis-like T-cell lymphoma, in remission
C86.40 Blastic NK-cell lymphoma not having achieved remission
C86.41 Blastic NK-cell lymphoma, in remission
C86.50 Angioimmunoblastic T-cell lymphoma not having achieved remission
C86.51 Angioimmunoblastic T-cell lymphoma, in remission
C86.60 Primary cutaneous CD30-positive T-cell proliferations not having achieved remission
C86.61 Primary cutaneous CD30-positive T-cell proliferations, in remission
C88.00 Waldenstrom macroglobulinemia not having achieved remission
C88.01 Waldenstrom macroglobulinemia, in remission
C88.20 Heavy chain disease not having achieved remission
C88.21 Heavy chain disease, in remission
C88.30 Immunoproliferative small intestinal disease not having achieved remission
C88.31 Immunoproliferative small intestinal disease, in remission
C88.40 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission
C88.41 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma], in remission
C88.80 Other malignant immunoproliferative diseases not having achieved remission
C88.81 Other malignant immunoproliferative diseases, in remission
C88.90 Malignant immunoproliferative disease, unspecified not having achieved remission
C88.91 Malignant immunoproliferative disease, unspecified, in remission
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C90.10 Plasma cell leukemia not having achieved remission
C90.11 Plasma cell leukemia in remission
C90.12 Plasma cell leukemia in relapse
C90.20 Extramedullary plasmacytoma not having achieved remission
C90.21 Extramedullary plasmacytoma in remission
C90.22 Extramedullary plasmacytoma in relapse
C90.30 Solitary plasmacytoma not having achieved remission
C90.31 Solitary plasmacytoma in remission
C90.32 Solitary plasmacytoma in relapse
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission
C91.11 Chronic lymphocytic leukemia of B-cell type in remission
C91.12 Chronic lymphocytic leukemia of B-cell type in relapse
C91.30 Prolymphocytic leukemia of B-cell type not having achieved remission
C91.31 Prolymphocytic leukemia of B-cell type, in remission
C91.32 Prolymphocytic leukemia of B-cell type, in relapse
C91.40 Hairy cell leukemia not having achieved remission
C91.41 Hairy cell leukemia, in remission
C91.42 Hairy cell leukemia, in relapse
C91.50 Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission
C91.51 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in remission
C91.52 Adult T-cell lymphoma/leukemia (HTLV-1-associated), in relapse
C91.60 Prolymphocytic leukemia of T-cell type not having achieved remission
C91.61 Prolymphocytic leukemia of T-cell type, in remission
C91.62 Prolymphocytic leukemia of T-cell type, in relapse
C91.A0 Mature B-cell leukemia Burkitt-type not having achieved remission
C91.A1 Mature B-cell leukemia Burkitt-type, in remission
C91.A2 Mature B-cell leukemia Burkitt-type, in relapse
C91.Z0 Other lymphoid leukemia not having achieved remission
C91.Z1 Other lymphoid leukemia, in remission
C91.Z2 Other lymphoid leukemia, in relapse
C92.00 Acute myeloblastic leukemia, not having achieved remission
C92.01 Acute myeloblastic leukemia, in remission
C92.02 Acute myeloblastic leukemia, in relapse
C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.11 Chronic myeloid leukemia, BCR/ABL-positive, in remission
C92.12 Chronic myeloid leukemia, BCR/ABL-positive, in relapse
C92.20 Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission
C92.21 Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission
C92.22 Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse
C92.30 Myeloid sarcoma, not having achieved remission
C92.31 Myeloid sarcoma, in remission
C92.32 Myeloid sarcoma, in relapse
C92.40 Acute promyelocytic leukemia, not having achieved remission
C92.41 Acute promyelocytic leukemia, in remission
C92.42 Acute promyelocytic leukemia, in relapse
C92.50 Acute myelomonocytic leukemia, not having achieved remission
C92.51 Acute myelomonocytic leukemia, in remission
C92.52 Acute myelomonocytic leukemia, in relapse
C92.60 Acute myeloid leukemia with 11q23-abnormality not having achieved remission
C92.61 Acute myeloid leukemia with 11q23-abnormality in remission
C92.62 Acute myeloid leukemia with 11q23-abnormality in relapse
C92.A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission
C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission
C92.A2 Acute myeloid leukemia with multilineage dysplasia, in relapse
C92.Z0 Other myeloid leukemia not having achieved remission
C92.Z1 Other myeloid leukemia, in remission
C92.Z2 Other myeloid leukemia, in relapse
C92.90 Myeloid leukemia, unspecified, not having achieved remission
C92.91 Myeloid leukemia, unspecified in remission
C92.92 Myeloid leukemia, unspecified in relapse
C93.00 Acute monoblastic/monocytic leukemia, not having achieved remission
C93.01 Acute monoblastic/monocytic leukemia, in remission
C93.02 Acute monoblastic/monocytic leukemia, in relapse
C93.10 Chronic myelomonocytic leukemia not having achieved remission
C93.12 Chronic myelomonocytic leukemia, in relapse
C93.Z0 Other monocytic leukemia, not having achieved remission
C93.Z2 Other monocytic leukemia, in relapse
C93.90 Monocytic leukemia, unspecified, not having achieved remission
C93.92 Monocytic leukemia, unspecified in relapse
C94.00 Acute erythroid leukemia, not having achieved remission
C94.01 Acute erythroid leukemia, in remission
C94.02 Acute erythroid leukemia, in relapse
C94.20 Acute megakaryoblastic leukemia not having achieved remission
C94.21 Acute megakaryoblastic leukemia, in remission
C94.22 Acute megakaryoblastic leukemia, in relapse
C94.30 Mast cell leukemia not having achieved remission
C94.31 Mast cell leukemia, in remission
C94.32 Mast cell leukemia, in relapse
C94.40 Acute panmyelosis with myelofibrosis not having achieved remission
C94.41 Acute panmyelosis with myelofibrosis, in remission
C94.42 Acute panmyelosis with myelofibrosis, in relapse
C94.6 Myelodysplastic disease, not elsewhere classified
C94.80 Other specified leukemias not having achieved remission
C94.81 Other specified leukemias, in remission
C94.82 Other specified leukemias, in relapse
C95.00 Acute leukemia of unspecified cell type not having achieved remission
C95.01 Acute leukemia of unspecified cell type, in remission
C95.02 Acute leukemia of unspecified cell type, in relapse
C95.10 Chronic leukemia of unspecified cell type not having achieved remission
C95.11 Chronic leukemia of unspecified cell type, in remission
C95.12 Chronic leukemia of unspecified cell type, in relapse
C96.0 Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis
C96.20 Malignant mast cell neoplasm, unspecified
C96.21 Aggressive systemic mastocytosis
C96.22 Mast cell sarcoma
C96.29 Other malignant mast cell neoplasm
C96.4 Sarcoma of dendritic cells (accessory cells)
C96.5 Multifocal and unisystemic Langerhans-cell histiocytosis
C96.6 Unifocal Langerhans-cell histiocytosis
C96.A Histiocytic sarcoma
C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
D45 Polycythemia vera
D46.0 Refractory anemia without ring sideroblasts, so stated
D46.1 Refractory anemia with ring sideroblasts
D46.20 Refractory anemia with excess of blasts, unspecified
D46.21 Refractory anemia with excess of blasts 1
D46.22 Refractory anemia with excess of blasts 2
D46.A Refractory cytopenia with multilineage dysplasia
D46.B Refractory cytopenia with multilineage dysplasia and ring sideroblasts
D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.4 Refractory anemia, unspecified
D46.Z Other myelodysplastic syndromes
D46.9 Myelodysplastic syndrome, unspecified
D47.01 Cutaneous mastocytosis
D47.02 Systemic mastocytosis
D47.1 Chronic myeloproliferative disease
D47.3 Essential (hemorrhagic) thrombocythemia
D47.4 Osteomyelofibrosis
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue
D47.9 Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified
D60.0 Chronic acquired pure red cell aplasia
D60.8 Other acquired pure red cell aplasias
D61.01 Constitutional (pure) red blood cell aplasia
D61.09 Other constitutional aplastic anemia
D61.1 Drug-induced aplastic anemia
D61.2 Aplastic anemia due to other external agents
D61.3 Idiopathic aplastic anemia
D61.810 Antineoplastic chemotherapy induced pancytopenia
D61.811 Other drug-induced pancytopenia
D61.818 Other pancytopenia
D61.82 Myelophthisis
D61.89 Other specified aplastic anemias and other bone marrow failure syndromes
D61.9 Aplastic anemia, unspecified
D75.81 Myelofibrosis
Z85.6 Personal history of leukemia
Z85.71 Personal history of Hodgkin lymphoma
Z85.72 Personal history of non-Hodgkin lymphomas
Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Group 2

(22 Codes)
Group 2 Paragraph

The following diagnoses are appropriate for the CLONOSEQ® test.

Group 2 Codes
Code Description
C83.30 Diffuse large B-cell lymphoma, unspecified site
C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
C83.32 Diffuse large B-cell lymphoma, intrathoracic lymph nodes
C83.33 Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
C83.34 Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb
C83.35 Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb
C83.36 Diffuse large B-cell lymphoma, intrapelvic lymph nodes
C83.37 Diffuse large B-cell lymphoma, spleen
C83.38 Diffuse large B-cell lymphoma, lymph nodes of multiple sites
C83.398 Diffuse large B-cell lymphoma of other extranodal and solid organ sites
C83.3A Diffuse large B-cell lymphoma, in remission
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission
C91.11 Chronic lymphocytic leukemia of B-cell type in remission
C91.12 Chronic lymphocytic leukemia of B-cell type in relapse
Z85.6 Personal history of leukemia
Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues

Group 3

(24 Codes)
Group 3 Paragraph

  • Refer also to Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A57772 and Billing and Coding: MolDX: Testing of Multiple Genes A57880.
  • For BCR-ABL1 testing - Refer to Billing and Coding: MolDX: BCR-ABL A55233 for BCR-ABL1 testing. Note: Though BCR-ABL1 may be present in other malignancies, for the purpose of MRD testing, single-gene testing of BCR-ABL1 is limited to CML and ALL.
  • MRD testing with NPM1 and PML-RARA is appropriate in Acute Promyelocytic Leukemia (APL). MRD testing is also appropriate in RUNX1-RUNX1T1, CBFB-MYH11, and NPM-1 mutated Acute Myeloid Leukemia (AML).

Group 3 Codes
Code Description
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C92.00 Acute myeloblastic leukemia, not having achieved remission
C92.01 Acute myeloblastic leukemia, in remission
C92.02 Acute myeloblastic leukemia, in relapse
C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
C92.11 Chronic myeloid leukemia, BCR/ABL-positive, in remission
C92.12 Chronic myeloid leukemia, BCR/ABL-positive, in relapse
C92.40 Acute promyelocytic leukemia, not having achieved remission
C92.41 Acute promyelocytic leukemia, in remission
C92.42 Acute promyelocytic leukemia, in relapse
C92.50 Acute myelomonocytic leukemia, not having achieved remission
C92.51 Acute myelomonocytic leukemia, in remission
C92.52 Acute myelomonocytic leukemia, in relapse
C92.60 Acute myeloid leukemia with 11q23-abnormality not having achieved remission
C92.61 Acute myeloid leukemia with 11q23-abnormality in remission
C92.62 Acute myeloid leukemia with 11q23-abnormality in relapse
C92.A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission
C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission
C92.A2 Acute myeloid leukemia with multilineage dysplasia, in relapse
C92.90 Myeloid leukemia, unspecified, not having achieved remission
C93.00 Acute monoblastic/monocytic leukemia, not having achieved remission
Z85.6 Personal history of leukemia

Group 4

(383 Codes)
Group 4 Paragraph

The following diagnoses are appropriate for MRD testing with Immunoglobulin (Ig) and/or T-cell receptor (TCR) gene rearrangement analysis.

Group 4 Codes
Code Description
C81.00 - C81.09 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site - Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites
C81.0A Nodular lymphocyte predominant Hodgkin lymphoma, in remission
C81.10 - C81.19 Nodular sclerosis Hodgkin lymphoma, unspecified site - Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites
C81.1A Nodular sclerosis Hodgkin lymphoma, in remission
C81.20 - C81.29 Mixed cellularity Hodgkin lymphoma, unspecified site - Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites
C81.2A Mixed cellularity Hodgkin lymphoma, in remission
C81.30 - C81.39 Lymphocyte depleted Hodgkin lymphoma, unspecified site - Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites
C81.3A Lymphocyte depleted Hodgkin lymphoma, in remission
C81.40 - C81.49 Lymphocyte-rich Hodgkin lymphoma, unspecified site - Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites
C81.4A Lymphocyte-rich Hodgkin lymphoma, in remission
C81.70 - C81.79 Other Hodgkin lymphoma, unspecified site - Other Hodgkin lymphoma, extranodal and solid organ sites
C81.7A Other Hodgkin lymphoma, in remission
C81.90 - C81.99 Hodgkin lymphoma, unspecified, unspecified site - Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C81.9A Hodgkin lymphoma, unspecified, in remission
C82.00 - C82.09 Follicular lymphoma grade I, unspecified site - Follicular lymphoma grade I, extranodal and solid organ sites
C82.0A Follicular lymphoma grade I, in remission
C82.10 - C82.19 Follicular lymphoma grade II, unspecified site - Follicular lymphoma grade II, extranodal and solid organ sites
C82.1A Follicular lymphoma grade II, in remission
C82.20 - C82.29 Follicular lymphoma grade III, unspecified, unspecified site - Follicular lymphoma grade III, unspecified, extranodal and solid organ sites
C82.2A Follicular lymphoma grade III, unspecified, in remission
C82.30 - C82.39 Follicular lymphoma grade IIIa, unspecified site - Follicular lymphoma grade IIIa, extranodal and solid organ sites
C82.3A Follicular lymphoma grade IIIa, in remission
C82.40 - C82.49 Follicular lymphoma grade IIIb, unspecified site - Follicular lymphoma grade IIIb, extranodal and solid organ sites
C82.4A Follicular lymphoma grade IIIb, in remission
C82.50 - C82.59 Diffuse follicle center lymphoma, unspecified site - Diffuse follicle center lymphoma, extranodal and solid organ sites
C82.5A Diffuse follicle center lymphoma, in remission
C82.60 - C82.69 Cutaneous follicle center lymphoma, unspecified site - Cutaneous follicle center lymphoma, extranodal and solid organ sites
C82.6A Cutaneous follicle center lymphoma, in remission
C82.80 - C82.89 Other types of follicular lymphoma, unspecified site - Other types of follicular lymphoma, extranodal and solid organ sites
C82.8A Other types of follicular lymphoma, in remission
C82.90 - C82.99 Follicular lymphoma, unspecified, unspecified site - Follicular lymphoma, unspecified, extranodal and solid organ sites
C82.9A Follicular lymphoma, unspecified, in remission
C83.00 - C83.09 Small cell B-cell lymphoma, unspecified site - Small cell B-cell lymphoma, extranodal and solid organ sites
C83.0A Small cell B-cell lymphoma, in remission
C83.10 - C83.19 Mantle cell lymphoma, unspecified site - Mantle cell lymphoma, extranodal and solid organ sites
C83.1A Mantle cell lymphoma, in remission
C83.30 - C83.38 Diffuse large B-cell lymphoma, unspecified site - Diffuse large B-cell lymphoma, lymph nodes of multiple sites
C83.390 Primary central nervous system lymphoma
C83.398 Diffuse large B-cell lymphoma of other extranodal and solid organ sites
C83.3A Diffuse large B-cell lymphoma, in remission
C83.50 - C83.59 Lymphoblastic (diffuse) lymphoma, unspecified site - Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites
C83.5A Lymphoblastic (diffuse) lymphoma, in remission
C83.70 - C83.79 Burkitt lymphoma, unspecified site - Burkitt lymphoma, extranodal and solid organ sites
C83.7A Burkitt lymphoma, in remission
C83.80 - C83.89 Other non-follicular lymphoma, unspecified site - Other non-follicular lymphoma, extranodal and solid organ sites
C83.8A Other non-follicular lymphoma, in remission
C83.90 - C83.99 Non-follicular (diffuse) lymphoma, unspecified, unspecified site - Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites
C83.9A Non-follicular (diffuse) lymphoma, unspecified, in remission
C84.00 - C84.09 Mycosis fungoides, unspecified site - Mycosis fungoides, extranodal and solid organ sites
C84.0A Mycosis fungoides, in remission
C84.10 - C84.19 Sezary disease, unspecified site - Sezary disease, extranodal and solid organ sites
C84.1A Sezary disease, in remission
C84.40 - C84.49 Peripheral T-cell lymphoma, not elsewhere classified, unspecified site - Peripheral T-cell lymphoma, not elsewhere classified, extranodal and solid organ sites
C84.4A Peripheral T-cell lymphoma, not elsewhere classified, in remission
C84.60 - C84.68 Anaplastic large cell lymphoma, ALK-positive, unspecified site - Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites
C84.6A Anaplastic large cell lymphoma, ALK-positive, in remission
C85.10 - C85.19 Unspecified B-cell lymphoma, unspecified site - Unspecified B-cell lymphoma, extranodal and solid organ sites
C85.1A Unspecified B-cell lymphoma, in remission
C85.20 - C85.29 Mediastinal (thymic) large B-cell lymphoma, unspecified site - Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites
C85.2A Mediastinal (thymic) large B-cell lymphoma, in remission
C85.80 - C85.89 Other specified types of non-Hodgkin lymphoma, unspecified site - Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites
C85.8A Other specified types of non-Hodgkin lymphoma, in remission
C85.90 - C85.99 Non-Hodgkin lymphoma, unspecified, unspecified site - Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
C85.9A Non-Hodgkin lymphoma, unspecified, in remission
C86.00 Extranodal NK/T-cell lymphoma, nasal type not having achieved remission
C86.01 Extranodal NK/T-cell lymphoma, nasal type, in remission
C86.10 Hepatosplenic T-cell lymphoma not having achieved remission
C86.11 Hepatosplenic T-cell lymphoma, in remission
C86.20 Enteropathy-type (intestinal) T-cell lymphoma not having achieved remission
C86.21 Enteropathy-type (intestinal) T-cell lymphoma, in remission
C86.30 Subcutaneous panniculitis-like T-cell lymphoma not having achieved remission
C86.31 Subcutaneous panniculitis-like T-cell lymphoma, in remission
C86.40 Blastic NK-cell lymphoma not having achieved remission
C86.41 Blastic NK-cell lymphoma, in remission
C86.50 Angioimmunoblastic T-cell lymphoma not having achieved remission
C86.51 Angioimmunoblastic T-cell lymphoma, in remission
C86.60 Primary cutaneous CD30-positive T-cell proliferations not having achieved remission
C86.61 Primary cutaneous CD30-positive T-cell proliferations, in remission
C88.00 Waldenstrom macroglobulinemia not having achieved remission
C88.01 Waldenstrom macroglobulinemia, in remission
C88.20 Heavy chain disease not having achieved remission
C88.21 Heavy chain disease, in remission
C88.30 Immunoproliferative small intestinal disease not having achieved remission
C88.31 Immunoproliferative small intestinal disease, in remission
C88.40 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] not having achieved remission
C88.41 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma], in remission
C88.80 Other malignant immunoproliferative diseases not having achieved remission
C88.81 Other malignant immunoproliferative diseases, in remission
C88.90 Malignant immunoproliferative disease, unspecified not having achieved remission
C88.91 Malignant immunoproliferative disease, unspecified, in remission
C90.00 Multiple myeloma not having achieved remission
C90.01 Multiple myeloma in remission
C90.02 Multiple myeloma in relapse
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission
C91.11 Chronic lymphocytic leukemia of B-cell type in remission
C91.12 Chronic lymphocytic leukemia of B-cell type in relapse
C91.60 Prolymphocytic leukemia of T-cell type not having achieved remission
C91.61 Prolymphocytic leukemia of T-cell type, in remission
C91.62 Prolymphocytic leukemia of T-cell type, in relapse
Z85.6 Personal history of leukemia
Z85.71 Personal history of Hodgkin lymphoma
Z85.72 Personal history of non-Hodgkin lymphomas
Z85.79 Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues
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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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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.

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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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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R5

Posted 09/26/2024 Under ICD-10 Codes that Support Medical Necessity Group 1: Codes
deleted C83.39, C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.0, C88.2, C88.3, C88.4, and C88.8. Added C81.0A, C81.1A, C81.2A, C81.3A, C81.4A, C81.7A, C81.9A, C82.0A, C82.1A, C82.2A, C82.3A, C82.4A, C82.5A, C82.6A, C82.8A, C82.9A, C83.0A, C83.1A, C83.390, C83.398, C83.3A, C83.5A, C83.7A, C83.8A, C83.9A, C84.0A, C84.1A, C84.4A, C84.6A, C84.7B, C85.1A, C85.2A, C85.8A, C85.9A, C86.00, C86.01, C86.10, C86.11, C86.20, C86.21, C86.30, C86.31, C86.40, C86.41, C86.50, C86.51, C86.60, C86.61, C88.00, C88.01, C88.20, C88.21, C88.30, C88.31, C88.40, C88.41, C88.80, C88.81, C88.90, and C88.91. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes deleted C83.39. Added C83.398 and C83.3A. Under ICD-10 Codes that Support Medical Necessity Group 4: Codes deleted C83.39, C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.3, and C88.4. Added C81.0A, C81.1A, C81.2A, C81.3A, C81.4A, C81.7A, C81.9A, C82.0A, C82.1A, C82.2A, C82.3A, C82.4A, C82.5A, C82.6A, C82.8A, C82.9A, C83.0A, C83.1A C83.390, , C83.398, C83.3A, C83.5A, C83.7A, C83.8A, C83.9A, C84.0A, C84.1A, C84.4A, C84.6A, C85.1A, C85.2A, C85.8A, C85.9A, C86.00, C86.01, C86.10, C86.11, C86.20, C86.21, C86.30, C86.31, C86.40, C86.41, C86.50, C86.51, C86.60, C86.61, C88.00, C88.01, C88.20, C88.21, C88.30, C88.31, C88.40, C88.41, C88.80, C88.81, C88.90, and C88.91. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/2024.

01/01/2024 R4

Posted 02/01/2024 Under CPT/HCPCS Codes Group 1: Codes the description was revised for 81450. Under CPT/HCPCS Codes Group 4: Codes the description was revised for 81450. This is due to the 2024 Annual/Q1 CPT/HCPCS Code Update and is effective 1/1/2024.

Under Article Text subheading Regarding NGS panels removed “DEX Z-code” and replaced with “DEX Z-Code®”. Under Article Text subheading Billing Instructions revised 1st sentence to remove “DEX™” and replaced with “DEX®”. Revised 3rd and 6th 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 1/1/2024.

01/01/2023 R3

Posted 01/26/2023: Under CPT/HCPCS Codes Group 1 and Group 4 Codes, 81450 had a description change. This revision is due to the Annual 2023/Q1 CPT/HCPCS Code Update and is effective 01/01/2023.

10/01/2022 R2

Posted 09/29/2022: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes, the description was revised for C84.40, C84.41, C84.42, C84.43, C84.44, C84.45, C84.46, C84.47, C84.48, C84.49 and C94.6. Under ICD-10 Codes that Support Medical Necessity Group 4: Codes, the description was revised for C84.40, C84.41, C84.42, C84.43, C84.44, C84.45, C84.46, C84.47, C84.48 and C84.49. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/01/2022.

07/28/2022 R1

Posted 07/28/2022- Under Article Text added verbiage, "Diffuse Large B-Cell Lymphoma (DLBCL)" to the Indicated Uses and Limitations box. Under ICD-10 Codes that Support Medical Necessity Group2: Codes added: C83.30 C83.31 C83.32 C83.33 C83.34 C83.35 C83.36 C83.37 C83.38 C83.39.This revision is retroactive to 02/18/2022.Review completed 07/07/2022.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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01/20/2023 01/01/2023 - 12/31/2023 Superseded View
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