MolDX: Mitochondrial Nuclear Gene Tests Coding and Billing Guidelines (CM00053, V2)
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October 28, 2015 - Updated 10.13.17

MolDX:  Mitochondrial Nuclear Gene Tests Coding and Billing Guidelines (CM00053, V2)

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

Mitochondrial disorders are a group of conditions caused by dysfunction in the mitochondrial respiratory chain. Current genetic testing methods are unable to detect mutations in all individuals with suspected mitochondrial disease, and there is no proven effective treatment for persons with a known mitochondrial disease. Therefore, CGS Administrators and the MolDX program contractor has determined mitochondrial nuclear gene tests do not support the required clinical utility for the established Medicare benefit category and are statutorily excluded tests.

To receive a mitochondrial nuclear panel service denial, please submit the following claim information:

  • CPT code 81479- Unlisted molecular pathology procedure
  • An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
    • For a voluntary issued ABN, append with GX modifier
    • To indicate a statutorily excluded service, append with a GY modifier
  • Select the appropriate diagnosis for the patient
  • Enter the appropriate DEX Z-codeTM identifier adjacent to each CPT code in the comment/narrative field for the following claim field/types:
    • Line SV202-7 for 837I Part A or Loop 2400 NTE02/SV 101-7 for 5010A1 837P Part B
    • Block 80 for Part A or Box 19 for Part B on paper claim

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,…”


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