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October 5, 2015 - Revised: 01.04.18

MammaPrint Billing and Coding Guidelines Update (CM00017, V3)

MammaPrint™, an FDA cleared in vitro microarray diagnostic test that uses gene expression profiling to analyze the gene activity of the identified tumor, has been assigned a unique identifier. To bill for MammaPrint services, please provide the following claim information:

  • CPT code 81520
  • Enter '1' in the Days/Unit field
  • 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
  • Select the appropriate diagnosis code

Note: MolDX expects this test may be performed upon occasion twice per patient lifetime for bilateral disease. Should a patient experience an additional occurrence, coverage may be considered with supporting documentation through the appeal process.

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