LCD Reference Article Billing and Coding Article

Billing and Coding: Genetic Testing for Lynch Syndrome

A57450

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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
A57450
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Genetic Testing for Lynch Syndrome
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34912, Genetic Testing for Lynch Syndrome. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

It has been recognized that there is some variation in the order of testing based on tissue availability, prevalence, patient history, test availability, testing turn-around time and patient treatment schedule. However, routine MMR germ-line mutation testing is not expected prior to appropriate screening (IHC/MSI). When MSI/IHC testing cannot be performed or is contradictory, claims for MMR germ-line testing exemptions will require the addition of the -KX modifier with the reported Current Procedural Terminology (CPT) code. The -KX modifier specifies that the “Requirements specified in the medical policy have been met. Documentation on file." Documentation is expected to be available upon request.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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

(111 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319 and 0238U.

Group 1 Codes
Code Description
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified
C16.6 Malignant neoplasm of greater curvature of stomach, unspecified
C16.8 Malignant neoplasm of overlapping sites of stomach
C16.9 Malignant neoplasm of stomach, unspecified
C17.0 Malignant neoplasm of duodenum
C17.1 Malignant neoplasm of jejunum
C17.2 Malignant neoplasm of ileum
C17.3 Meckel's diverticulum, malignant
C17.8 Malignant neoplasm of overlapping sites of small intestine
C17.9 Malignant neoplasm of small intestine, unspecified
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C22.0 Liver cell carcinoma
C22.1 Intrahepatic bile duct carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C24.0 Malignant neoplasm of extrahepatic bile duct
C24.9 Malignant neoplasm of biliary tract, unspecified
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C54.0 Malignant neoplasm of isthmus uteri
C54.1 Malignant neoplasm of endometrium
C54.2 Malignant neoplasm of myometrium
C54.3 Malignant neoplasm of fundus uteri
C54.8 Malignant neoplasm of overlapping sites of corpus uteri
C54.9 Malignant neoplasm of corpus uteri, unspecified
C55 Malignant neoplasm of uterus, part unspecified
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C56.9 Malignant neoplasm of unspecified ovary
C57.00 Malignant neoplasm of unspecified fallopian tube
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
C57.10 Malignant neoplasm of unspecified broad ligament
C57.11 Malignant neoplasm of right broad ligament
C57.12 Malignant neoplasm of left broad ligament
C57.20 Malignant neoplasm of unspecified round ligament
C57.21 Malignant neoplasm of right round ligament
C57.22 Malignant neoplasm of left round ligament
C57.3 Malignant neoplasm of parametrium
C57.4 Malignant neoplasm of uterine adnexa, unspecified
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C66.1 Malignant neoplasm of right ureter
C66.2 Malignant neoplasm of left ureter
C66.9 Malignant neoplasm of unspecified ureter
C68.8 Malignant neoplasm of overlapping sites of urinary organs
C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of cerebral ventricle
C71.6 Malignant neoplasm of cerebellum
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of overlapping sites of brain
C71.9 Malignant neoplasm of brain, unspecified
D12.0 Benign neoplasm of cecum
D12.1 Benign neoplasm of appendix
D12.2 Benign neoplasm of ascending colon
D12.3 Benign neoplasm of transverse colon
D12.4 Benign neoplasm of descending colon
D12.5 Benign neoplasm of sigmoid colon
D12.6 Benign neoplasm of colon, unspecified
K63.5 Polyp of colon
L85.3 Xerosis cutis
Z85.00* Personal history of malignant neoplasm of unspecified digestive organ
Z85.038* Personal history of other malignant neoplasm of large intestine
Z85.048* Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.42* Personal history of malignant neoplasm of other parts of uterus
Z85.43* Personal history of malignant neoplasm of ovary
Z85.53* Personal history of malignant neoplasm of renal pelvis
Z85.54* Personal history of malignant neoplasm of ureter
Z85.59* Personal history of malignant neoplasm of other urinary tract organ
Z85.841* Personal history of malignant neoplasm of brain
Z86.0100* Personal history of colon polyps, unspecified
Z86.0101* Personal history of adenomatous and serrated colon polyps
Z86.0102* Personal history of hyperplastic colon polyps
Z86.0109* Personal history of other colon polyps
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Diagnosis codes Z85.00, Z85.038, Z85.048, Z85.42, Z85.43, Z85.53, Z85.54, Z85.59, Z85.841, Z86.0100, Z86.0101, Z86.0102, and Z86.0109 should not be billed as the primary diagnosis.

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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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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N/A

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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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

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
N/A N/A
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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
10/01/2024 R3

Article revised and published on 10/24/2024 effective for dates of service on and after 10/01/2024 to reflect annual ICD-10-CM code updates. The following ICD-10-CM codes that Support Medical Necessity in Group 1 have been deleted and therefore have been removed from the article: Z86.010. The following ICD-10-CM codes that Support Medical Necessity in Group 1 have been added to the article: Z86.0100*, Z86.0101*, Z86.0102*, and Z86.0109*. Asterisk descriptions were added to the current statement in the Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation section for codes Z86.0100*, Z86.0101*, Z86.0102*, and Z86.0109*: these codes should not be billed as the primary diagnosis. Minor formatting changes were made throughout the article.

10/01/2021 R2

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM code has been added to the article: C56.3 in Group 1 Codes. Minor formatting changes have been made.

01/01/2021 R1

Article revised and published on 02/11/2021 effective for dates of service on and after 01/01/2021 to reflect the Annual HCPCS/CPT Code Updates. CPT code 0238U has been added to the CPT/HCPCS Code Group 1 and to the ICD-10 Codes that support medical necessity Group 1 Paragraph. CPT code 81288 has undergone either a short description and/or long description change. Depending on which description is used in this article, there may not be any change in how the code displays. Minor formatting changes were made throughout the article.

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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
L34912 - Genetic Testing for Lynch Syndrome
Related National Coverage Documents
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Updated On Effective Dates Status
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