August 5, 2013
CYP2C9 and/or VKORC1 Gene Testing for Warfarin Response: Coding and Claim Submission Guidelines
These instructions are effective for dates of service on or after January 1, 2013.
Based on National Coverage Determination (NCD) 90.1 - Pharmacogenomic Testing for Warfarin Response, gene testing on CYP2C9 and/or VKORC1 will only be covered through coverage with evidence development (CED). Testing will be limited to once in a lifetime per beneficiary. CGS will reimburse only genetic testing services for beneficiaries who meet the NCD criteria and are enrolled in a clinical trial.
Lab providers that perform services on eligible beneficiaries described by CPT codes 81227 and 81355 must submit the following information on claims for gene testing for warfarin response:
- HCPCS code: G9143- warfarin responsiveness testing
- ICD-9-CM code: V70.7- Examination of patient in clinical trial
- HCPCS modifier Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Note:
- Report only HCPCS code G9143 and 1 unit of service. Do not report CPT codes 81227 and/or 81355 on the claim.
- To facilitate payment, we strongly suggest that you submit the eight-digit clinical trial number:
- Electronic claims: Loop 2400, NTE02, or SV101-7
- Paper claims: Box 19
- CMS MLN Matters article MM6715, "Pharmacogenomic Testing for Warfarin Response
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- CMS NCD 90.1
- Pharmacogenomic Testing for Warfarin Response
References: