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October 30, 2015 - Revised: 05.17.17

HAX1 Gene Sequencing Coding and Billing Guidelines (M00085, V2)

Effective for dates of service on and after February 6, 2013.

HAX1 gene sequencing may be performed during the diagnosis of HAX1-related Congentital Neutropenia (CN) and Kostmann disease. A HAX1 mutation will only provide reproductive risk stratification for CN. In individuals with Kostmann syndrome, a HAX1 mutation will not change the medical management. Therefore, MolDX has determined HAX1 gene sequencing is a statutorily excluded test. In addition to single gene testing, MolDX will also deny panels of tests that include the HAX1 gene.

To receive a HAX1 gene sequencing service denial, please submit the following claim information:

CPT code 81479
An Advance Beneficiary Notice of Non-Coverage (ABN) is not required for statutorily excluded services.
- For a voluntary issued ABN, append with HCPCS modifier GX
- To indicate a valid ABN is on file for a known statutorily excluded service, append with HCPCS modifier GY
Select the appropriate diagnosis for the patient
For CPT non-NOC codes, 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

Reference: 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,…"

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

HAX1 Gene Sequencing Coding and Billing Guidelines (M00085, V2)

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