LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: FDA-Approved KRAS Tests

A54472

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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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General Information

Source Article ID
N/A
Article ID
A54472
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: FDA-Approved KRAS Tests
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
07/14/2022
Revision Ending Date
N/A
Retirement Date
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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

Two tests have met the Food and Drug Administration (FDA) criteria for KRAS genetic testing:

    1. Effective 7/6/2012
      therascreen® KRAS to detect 7 somatic mutations in the human KRAS oncogene was developed to aid in the identification of colorectal cancer (CRC) patients for treatment with Erbitux® (cetuximab).
    2. Effective 5/7/2015
      cobas® KRAS to detect mutations in codons 12 and 13 of the KRAS gene was developed to aid in identification of CRC patients for treatment with Erbitux® (cetuximab) or Vectibix® (panitumumab).


To report an FDA approved or laboratory developed test (LDT) KRAS, service, please submit the following claim 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
  • Select the appropriate ICD-10-CM diagnosis.


NOTE: MolDX will apply National Provider Identifier (NPI) to ID editing on FDA approved KRAS kits. All labs that submit claims for a KRAS, codon 12 and 13 test kit MUST register the test and confirm the UNMODIFIED use of the kit. Tests may be registered on the DEXTM Diagnostics Exchange: https://app.dexzcodes.com/login

This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.

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Coding Information

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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(37 Codes)
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Group 1 Codes
Code Description
C77.0 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
C77.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
C77.2 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
C77.3 Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.1 Secondary malignant neoplasm of mediastinum
C78.2 Secondary malignant neoplasm of pleura
C78.39 Secondary malignant neoplasm of other respiratory organs
C78.4 Secondary malignant neoplasm of small intestine
C78.5 Secondary malignant neoplasm of large intestine and rectum
C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C78.80 Secondary malignant neoplasm of unspecified digestive organ
C78.89 Secondary malignant neoplasm of other digestive organs
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pelvis
C79.11 Secondary malignant neoplasm of bladder
C79.19 Secondary malignant neoplasm of other urinary organs
C79.2 Secondary malignant neoplasm of skin
C79.31 Secondary malignant neoplasm of brain
C79.32 Secondary malignant neoplasm of cerebral meninges
C79.49 Secondary malignant neoplasm of other parts of nervous system
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
C79.63 Secondary malignant neoplasm of bilateral ovaries
C79.71 Secondary malignant neoplasm of right adrenal gland
C79.72 Secondary malignant neoplasm of left adrenal gland
C79.81 Secondary malignant neoplasm of breast
C79.82 Secondary malignant neoplasm of genital organs
C79.89 Secondary malignant neoplasm of other specified sites
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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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

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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
07/14/2022 R15

This article is being revised because the article is showing as being related to L35025 on MCD side, it is related to version 91. It is not displaying in the Manage Related Documents list to relate to L35025 yet in the Local Coverage website because the current versions A54472 (version 29), is not approved. Article is therefore being approved to display in the manage related documents list.

07/14/2022 R14

Under Article Text revised verbiage regarding instructions on how to submit claims information. Under CPT/HCPCS Codes Group1: Codes added 81479 and 81276. This revision is effective on 7/14/2022. 

03/03/2022 R13

Under CMS National Coverage Policy added regulation, Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Under Article Text, revised sentence to read, “To report an FDA approved or laboratory developed test (LDT) KRAS, codon 12 and 13 test kit service, please submit the following claim information.” This revision is effective on 03/03/2022. 

10/01/2021 R12

Under Article Text corrected hyperlink for DEX webpage. Acronyms were defined and inserted where appropriate throughout the article. Formatting was corrected throughout the article. This revision is effective 10/1/2021.

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added C79.63. This revision is due to the Annual ICD-10 update and will become effective on 10/1/21.

10/24/2019 R11

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. Under CPT/HCPCS Codes Group 1: Codes added CPT® code 81275. CPT® was inserted throughout the article where applicable.

02/26/2018 R10 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
01/29/2018 R9 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this article begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this article. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
12/21/2017 R8

Corrected the Diagnostics Exchange Web address and name from McKesson Diagnostics Exchange to DEXTM Diagnostics Exchange.

12/14/2017 R7

Removed modifier 22 references.

12/07/2017 R6

Completed Annual Review. Added Part A Contract Numbers and DEX Z-Code Identifier information.

02/24/2016 R5 Added statement that MolDX will approve all future FDA-approved indications to the end of article.
12/10/2015 R4 Reverted back to SV101-7 and for trade mark purposes, replaced ID/MolDX identifier/Z-Code to read Z-Code™ Identifier
11/19/2015 R3 Replaced SV101-7 with MID
10/29/2015 R2 Annual review completed. No changes needed.
10/01/2015 R1 Removed ICD-9 and ICD-10 codes from article text and added them to the ICD-9 field. Added contractor numbers 11302, 11402, 11502.
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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
L35025 - MolDX: Molecular Diagnostic Tests (MDT)
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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Public Versions
Updated On Effective Dates Status
02/20/2023 07/14/2022 - N/A Currently in Effect You are here
07/07/2022 07/14/2022 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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