RETIRED LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: L1CAM Gene Sequencing

A55192

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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
A55192
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: L1CAM Gene Sequencing
Article Type
Billing and Coding
Original Effective Date
02/16/2017
Revision Effective Date
02/01/2024
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, Sec. 1862 (1)(A) Statutory Exclusion covers diagnostic testing “except for items and services that are not 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

Effective for dates of service on and after January 29, 2013.

L1 syndrome refers to multiple disorders including X-linked hydrocephalus with aqueduct of Sylvius (HSAS) stenosis, MASA syndrome (Mental retardation, Aphasia, Spastic paraplegia, Adducted thumbs), SPG1 (X-linked complicated hereditary spastic paraplegia type 1), and X-linked complicated corpus callosum agenesis. Because there are many potential underlying causes for congenital hydrocephalus, including syndromic and nonsyndromic cases, recurrence risk and implications for family members is based upon underlying etiology. Genetic testing of the L1CAM gene is used to confirm a clinical diagnosis and provide recurrence risk. Therefore, the MolDX Team has determined L1CAM full gene sequencing is a statutorily excluded test.

To receive a L1CAM gene sequencing service denial, please submit the following claim information:

  • CPT code 81407 L1CAM 
  • CPT code 81470-X-linked intellectual disability genomic sequence analysis panel
  • CPT code 81471-X-linked intellectual disability genomic sequence analysis panel duplication/deletion
  • 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
  • Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information. 
  • 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

Response To Comments

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Coding Information

Bill Type Codes

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

Group 1

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ICD-10-PCS Codes

Group 1

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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 R9

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.

02/01/2024 R8

Posted 02/01/2024 Review completed with no change in coverage.

01/27/2022 R7

01/27/2022 Review completed with no change in coverage.

11/01/2019 R6

Content moved to the new template. Title changed from: MolDX: L1CAM Gene Sequencing Coding and Billing Guidelines to Billing and Coding: MolDX: L1CAM Gene Sequencing. Under Article Text deleted the statement “Select the appropriate diagnosis for the patient” & Title XVIII of the Social Security Act, §1862(a)(1)(A) which has been added to the CMS National Coverage Policy section. Added GX & GY modifiers to the modifier table. Moved CPT 81407 from CPT/HCPCS Code Group 1 to CPT/HCPCS code Group 2 and added “CPT codes that are also referenced in other articles.” Review completed 11/25/2019.

01/01/2019 R5

02/01/2019-Code update: added 81470 & 81471.

01/01/2019 R4

01/01/2019-Code update: 81407 long description changes.

06/01/2018 R3

06/01/2018-Annual review completed 05/03/2018.

07/01/2017 R2

07/01/2017-Annual review completed 06/09/2017. Updated billing instructions, added Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information. Added Part A billing instructions & updated Part B instructions.

02/16/2017 R1 01/01/2017-Code update-description change 81407.
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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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Public Versions
Updated On Effective Dates Status
06/27/2024 02/01/2024 - 06/27/2024 Retired You are here
01/23/2024 02/01/2024 - N/A Superseded View
01/19/2022 01/27/2022 - 01/31/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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