Persius/hicric huggingface dataset:
Billing and Coding: MolDX: SMPD1 Genetic Testing

Effective for dates of service on and after February 7, 2013.

Mutations found in sphingomyelin phosphodiesterase 1, (SMPD1) acid lysomal,
are associated with Niemann-Pick Disease, characterized by acid
sphingomyelinase (ASM) deficiency. For infants and children, SMPD1 genetic
testing is used to confirm the clinical findings from blood tests to diagnose
ASM. Genetic testing for adults is used to screen the population for potential
carriers of the mutation. Therefore, the MolDX team has determined that SMPD1
genetic testing is not a Medicare benefit and is a statutorily excluded
service. In addition to single disease testing, MolDX will also deny panels of
tests that include a SMPD1 gene test as a statutorily excluded service.  
  
To receive a SMPD1 test denial, please submit the following claim information:

  * CPT code 81330- SMPD1, common variants
  * CPT code 81412 - Ashkenazi Jewish Associated Disorders 
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a statutorily excluded service, append with a GY modifier. An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
Billing and Coding: MolDX: STAT3 Gene Testing

Effective for dates of service on and after June 26, 2013.  
  
STAT3 gene testing may be performed during the diagnosis of Autosomal Dominant
Hyper IgE Syndrome (AD-HIES). Since management is not determined by the
presence or absence of a STAT3 mutation in patients with a probable clinical
diagnosis, the MolDx Contractor has determined STAT3 analysis is a statutorily
excluded test.  
  
To receive a STAT3 analysis service denial, please submit the following claim
information:

  * CPT code 81405 - STAT3, targeted sequence analysis 
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services. 
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * 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-CodeTM 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-CodeTM 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
Billing and Coding: MolDX: SULT4A1 Genetic Testing

Sulfotransferase 4A1 (SULT4A1) is an enzyme found in the brain that interacts
with numerous neuroactive molecules, including some catecholamines and neural
steroids. Findings suggest the SULT4A1-1 haplotype of SULT4A1 is associated
with enhanced response to antipsychotic drug therapy. At present there is
insufficient evidence to support SULT4A1 genotyping to determine medical
management. Therefore, the MolDX Team has determined SULT4A1 genetic testing
is not a Medicare benefit and is a statutorily excluded service. In addition
to single gene testing, MolDX will also deny panels of tests that include the
SULT4A1 gene as a statutorily excluded service.

To receive a SULT4A1 test denial, please submit the following claim
information:

  * CPT code 81479
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services 
    * For a voluntary issued ABN, append with GX HCPCS modifier
    * To indicate a statutorily excluded service, append with a GY HCPCS modifier
  * 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-CodeTM 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-CodeTM 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
Billing and Coding: MolDX: TERC Gene Tests

Effective for dates of service on and after June 25, 2013.  
  
Since the associated conditions associated with telomerase RNA component
(TERC) gene testing is limited to reproductive risk assessment, the MolDX team
has determined TERC gene testing is a statutorily excluded service. MolDX will
also deny tests that include one or more of TERC analysis reported with CPT
code 81479 as a statutorily excluded service.  
  
To receive a TERC analysis service denial, please submit the following claim
information:

  * CPT 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 valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * Select the appropriate diagnosis for the patient
  * 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-CodeTM 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-CodeTM 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
Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient

In response to provider requests, Noridian Healthcare Solutions, LLC
(Noridian) provides the following key points related to the "incident to"
regulations in the outpatient hospital setting. Note: There is no "incident
to" in the inpatient setting.  
  
Medicare may reimburse the costs of services provided either:  
  
1\. delivered personally by eligible practitioners, e.g., MD, NP, PA; or  
2\. delivered by hospital personnel working "incident to" the eligible
practitioner's care.  
  
When hospital personnel provide services, the following payment requirements
must be met. Services delivered incident to the services of an eligible
practitioner must:  
  
o Be an integral although **incidental part** of a physician's/non-physician
practitioner's (NPP's) professional service(s) and, hence, must always occur
after an initial patient care service is provided by an eligible practitioner;  
  
o Be delivered in accordance with a **valid and signed order** , i.e., written
by "a practitioner who is authorized to write orders by hospital policy and in
accordance with state law..." 42 CFR482.12(c);  
  
o Be delivered under the **supervision of a physician** who is an employee or
has another contractual relationship with the hospital and is **immediately
available** to provide assistance to the personnel delivering the service;  
  
"Immediately available" in the outpatient hospital setting means that the
physician must be **available in the same time-frame as the personnel
designated to manage cardiac arrests** (codes) in the hospital.  
  
The supervisor need not be in the same department as the ordering
physician/NPP or in the same department in which the services are rendered but
must be **on the physical premises** where and when the patient receives
services.  
  
The physician/NPP that provides the oversight may not bill for the services of
hospital employees. Only the hospital may bill for the services of hospital
employees.  
  
All service providers must work in accordance with their skills, licensure,
and/or other hospital and other Medicare requirements.  
  
 **  **
Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient

In response to provider requests, Noridian Healthcare Solutions, LLC
(Noridian) provides the following key points related to the "incident to"
regulations in the outpatient hospital setting. Note: There is no "incident
to" in the inpatient setting.  
  
Medicare may reimburse the costs of services provided either:  
  
1\. delivered personally by eligible practitioners, e.g., MD, NP, PA; or  
2\. delivered by hospital personnel working "incident to" the eligible
practitioner's care.  
  
When hospital personnel provide services, the following payment requirements
must be met. Services delivered incident to the services of an eligible
practitioner must:  
  
o Be an integral although **incidental part** of a physician's/non-physician
practitioner's (NPP's) professional service(s) and, hence, must always occur
after an initial patient care service is provided by an eligible practitioner;  
  
o Be delivered in accordance with a **valid and signed order** , i.e., written
by "a practitioner who is authorized to write orders by hospital policy and in
accordance with state law..." 42 CFR482.12(c);  
  
o Be delivered under the **supervision of a physician** who is an employee or
has another contractual relationship with the hospital and is **immediately
available** to provide assistance to the personnel delivering the service;  
  
"Immediately available" in the outpatient hospital setting means that the
physician must be **available in the same time-frame as the personnel
designated to manage cardiac arrests** (codes) in the hospital.  
  
The supervisor need not be in the same department as the ordering
physician/NPP or in the same department in which the services are rendered but
must be **on the physical premises** where and when the patient receives
services.  
  
The physician/NPP that provides the oversight may not bill for the services of
hospital employees. Only the hospital may bill for the services of hospital
employees.  
  
All service providers must work in accordance with their skills, licensure,
and/or other hospital and other Medicare requirements.  
  
 ** **
Billing and Coding: MolDX: TP53 Gene Test

Effective for dates of service on and after June 24, 2013.  
  
TP53 gene testing may be performed during the diagnosis of Li-Fraumeni
syndrome (LFS), a cancer predisposition syndrome associated with the
development of specific tumors. Clinical symptoms and diagnosis usually occur
prior to Medicare eligibility and carrier testing is not a covered benefit.  
  
To receive a TP53 gene sequencing service denial, please submit the following
claim information:

  * Select the appropriate CPT code
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services. 
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * Select the appropriate diagnosis for the patient
  * Enter the appropriate DEX Z-CodeTM 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 DEX Z-CodeTM 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
Billing and Coding: MolDX: Germline testing for use of PARP inhibitors

The United States (U.S.) Food and Drug Administration (FDA) has approved
several poly ADP-ribose polymerase (PARP) inhibitor treatments indicated for
patients with ovarian cancer, breast cancer, pancreatic cancer, and prostate
cancer.

Results of tests that assess for deleterious variants in homologous
recombination repair (HRR) genes such as BRCA1 and 2 can be used as an aid in
patients who are being considered for treatment with PARP inhibitors in
accordance with published guidelines and approved therapeutic product
labeling. These genes are often tested as part of routine management of these
cancer patients as part of services that interrogate a panel of genes as
described in LCD L39040. In rare circumstances limited testing for only a
select group of genes may be tested to ensure compliance with FDA indicated
drug usage, wherein additional genes outlined in guidelines such as the NCCN
are not necessary because the patient does not meet testing criteria for
larger panels.

According to criteria defined by L39040, billing for these services can occur
in the following situation:

  * The patient meets clinical indication for immediate use of a PARP inhibitor for an FDA-approved use AND
  * The patient has had no previous germline testing for hereditary cancer or somatic testing of the same cancer that included the genes necessary for testing AND
  * The patient does not meet germline testing requirements per existing guidelines or standards of care outlined in policy L39040 requiring more comprehensive testing.

To report a service, please submit the following claim information:

  * Select appropriate CPT code
  * One (1) unit of service
  * Assigned DEX Z-CodeTM Identifier in the 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
    * Submit the assigned Z-CodeTM Identifier on an attachment to the claim form for paper claim
  * Enter the appropriate DEX Z-CodeTM 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 at least one ICD-10-CM diagnosis code.
Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy

A covered colonoscopy that is attempted but cannot be completed because of
extenuating circumstances is considered to be an incomplete colonoscopy (the
inability to advance the colonoscope to the cecum or to the colon-small
intestine anastomosis due to unforeseen circumstances). The failed procedure
is billed and paid using CPT code 45378, HCPCS code G0105 or G0121, or CPT
code 44388, if attempting to perform the colonoscopy through an existing
stoma. Modifier "-53" (discontinued procedure) must be appended to any
procedure code submitted when billing for a failed colonoscopy attempt.  
  
When a covered colonoscopy is next attempted and completed, Medicare will pay
for that colonoscopy according to its payment methodology for this procedure,
as long as all coverage conditions are met. This applies to both screening and
diagnostic colonoscopies.
Billing and Coding: MolDX: Oncotype DX Breast Cancer Assay

**NOTE:** The Oncotype DX Breast Cancer Assay and the Oncotype DX DCIS Score
are different tests and should NOT be submitted with the same Z-Code
Identifier. Because this article ONLY addresses Oncotype DX Breast, the
diagnosis codes for breast carcinoma in situ have been removed.  
  
Oncotype DX Breast was developed for patients with the following findings:

  * estrogen-receptor positive, node-negative carcinoma of the breast
  * estrogen-receptor positive micrometastases of carcinoma of the breast, and
  * estrogen-receptor positive breast carcinoma with 1-3 positive nodes

To bill an Oncotype Breast service, please provide the following claim
information:

  * CPT code 81519 - Oncology (breast)
  * Enter "1" in the Days/Unit field
  * Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
  * Enter assigned DEX Z-CodeTM Identifier in the comment/narrative field for the following Part B claim field/types:
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Submit assigned Z-CodeTM Identifier on an attachment to the claim form for paper claim
  * Enter the appropriate DEX Z-CodeTM 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 ICD-10-CM code.
Billing and Coding: MolDX: Oncotype DX Colon Cancer Assay Update

The Oncotype DX Colon Cancer Assay, developed to predict the recurrence risk
for patients with Stage II colon cancer, has been assigned a unique
identifier. To bill an Oncotype DX Colon service, please provide the following
claim information:

  * CPT code 81525-Oncology (colon), mRNA gene expression of 12 genes 
  * Enter "1" in the Days/Unit field
  * 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-CodeTM 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-CodeTM 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 ICD-10-CM code:
Billing and Coding: MolDX: VEGFR2 Tests

Effective for dates of service on and after 05/03/2013.

Vascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been
found to be oncogenic. Current studies have targeted VEGFR2 as a potential
therapeutic option. However, at present there is insufficient evidence to
establish a clear association between VEGFR2 mutations and treatment response.
Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily
excluded service. MolDX will also deny panels of tests that include the VEGFR2
receptor.

To receive a VEGFR2 service denial, please submit the following claim
information:

  * CPT code 81479
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services. 
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * Enter the appropriate DEX Z-CodeTM 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 DEX Z-CodeTM 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
Billing and Coding: MolDx: BCR-ABL

Effective for dates of service on and after 4/15/13.  
  
Breakpoint testing for BCR-ABL1 is commonly performed as a combination or
panel of tests (major minor and other breakpoints). To report multiple tests
assigned a single ID, submit CPT code 81479. This guideline includes the
following (C)CPT code combinations:

  * 81206 and 81207 
  * 81206, 81207, and 81208

CPT codes 81206, 81207, and 81208 may only be reported when performed as a
single test.

To submit a claim for BCR-ABL translocation analysis by NGS, use CPT 81479 and
one (1) UOS with the assigned DEX Z-code.

To report the FDA-approved MRDx BCR-ABL Test use the CPT code 0040U.

Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57880 for
additional information regarding single-gene and panel testing of genes.

  * 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-CodeTM 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-CodeTM 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
Billing and Coding: MolDX: Arrhythmogenic Right Ventricular
Dysplasia/Cardiomyopathy (ARVD/C) Testing

Effective for dates of service on and after February 7, 2013.  
ARVD/C, characterized by fatty replacement of heart cells predominantly in the
right ventricle of the heart, is most often inherited as an autosomal dominant
disease that may be associated with testing in at least seven genes (RYR2,
TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in
panels of 5-7 of these genes and disease-causing mutation is expected to be
identified in 42-55% of cases. Testing would be performed to confirm an
established diagnosis or on individuals already diagnosed with ARVD/C to
identify family members at risk. Therefore, MolDX has determined that testing
for ARVD/C is a statutorily excluded test.  
  
To receive an ARVD/C panel test denial, please submit the following claim
information:

  * CPT code 81439
  * 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
  * 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-CodeTM 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-CodeTM 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
Billing and Coding: MolDX: Fragile X

The MolDX Team has determined that Fragile X testing is not a Medicare covered
service. Screening in the absence of signs and symptoms of an illness or
injury is not defined as a Medicare benefit. Therefore, MolDX will deny
testing for Fragile X as a statutorily excluded service.  
  
To receive a Fragile X service denial, please submit the following claim
information:

  * Select the appropriate CPT code: 
    * 81243- FMR1
    * 81244- FMR1, methylation analysis
    * 81470 - X-linked intellectual disability genomic sequence analysis panel
    * 81471 - X-linked intellectual disability genomic sequence analysis panel duplication / deletion
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services. 
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier

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
    * Item 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

  
NOTE: When entering the DEX Z-Code on the SV101-7 documentation field for
Part B claims please do not add additional characters or information on the
line.