This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Documentation Requirements:
Documentation must be adequate to verify that coverage guidelines listed in the Local Coverage Determination (LCD) have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).
Examples of documentation requirements of the ordering physician/non-physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results).
Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.
Documentation requirements for LDT(s)/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility.
Specific Documentation Requirements
The following are the appropriate field/types for Part B claims:
- Loop 2400 or SV101-7 for the 5010A1 837P
- BOX 19 for paper claim
The following are the appropriate field/types for Part A claims:
- Line SV202-7 for 837I electronic claim
- Block 80 for the UB04 claim form
Utilization Guidelines:
Screening services such as pre-symptomatic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly affects the management of the patient.
Serum immunofixation electrophoresis (CPT code 86334) will be denied when submitted with PLA code 0077U.
PLA code 0077U shall only be billed twice per date of service.
