RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: MMACHC Test

A55191

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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
A55191
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: MMACHC Test
Article Type
Billing and Coding
Original Effective Date
02/16/2017
Revision Effective Date
11/30/2023
Revision Ending Date
06/27/2024
Retirement Date
06/27/2024

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Article Guidance

Article Text

Methylmalonic aciduria (cobalamin deficiency) cblC type, with homocystinuria (MMACHC) is associated with the most common error of vitamin B12 metabolism. Although considered a disease of infancy or childhood, some individuals develop symptoms in adulthood. However to date, the exact function of the protein encoded by this gene is not known. Therefore, MMACHC testing does not meet the clinical utility requirements for a Medicare Benefit and is considered a statutorily excluded service. MolDX will also deny panels of tests that include the MMACHC gene.

To receive a MMACHC service denial, please submit the following claim information:

  • CPT code 81404-MMACHC, fgs 
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    • For a voluntary issued ABN, append with GX modifier
    • To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  • 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 MolDX ID (MID) field for the 5010A1 837P
    • Box 19 for paper claim
  • Enter 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

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

(2 Codes)
Group 1 Paragraph

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Group 1 Codes
Code Description
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
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ICD-10-CM Codes that Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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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
06/27/2024 R8

Posted 06/27/2024. This article is being retired because it is not supported by a Local Coverage Determination (LCD) and does not comply with current 21st Century Cures requirements.

11/30/2023 R7

Posted 11/30/2023: Biannual review completed with no change in coverage. No changes were made to the article.

11/25/2021 R6

11/25/2021-Review completed 10/14/2021. Updated CMS National Coverage Policy section.

11/01/2019 R5

Content moved to the new template. Under Article Text deleted the statement “Select the appropriate diagnosis for the patient” & Title XVIII of the Social Security Act, §1862(a)(1)(A) has been added to the CMS National Coverage Policy section and removed from the Article Text section. Added GX & GY modifiers to the modifier table. Review completed 11/13/2019.

01/01/2019 R4

01/01/2019-Code update-81404 long description changes.

12/01/2018 R3

12/01/2018-Annual Review completed 11/07/2018.

01/01/2018 R2

01/01/2018-code update-81404 description change & annual review completed 12/07/2017.

03/01/2017 R1 03/01/2017- Annual review 02/02/2017. Added Part A claim submission info and added new trademark for McKesson Z-code ID.
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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
L36807 - 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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Other URLs
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Public Versions
Updated On Effective Dates Status
06/27/2024 11/30/2023 - 06/27/2024 Retired You are here
11/20/2023 11/30/2023 - N/A Superseded View
11/16/2021 11/25/2021 - 11/29/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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