Article - Billing and Coding: Bladder/Urothelial Tumor Markers (A56471)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36975).CGS Administrators, LLCwill only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPTcode 88120 or 88121 as appropriateEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/typesLoop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formLaboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.Select CPTcode 88120 or 88121 as appropriateEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formTo register a test for a DEX Z-Code identifier, follow the registration process outlined in the MolDX Test Registration article located on the MolDX site. Once an identifier has been assigned, submit a Technical Assessment (TA) request as documented on the MolDX site TA Process.Note:Physicians may NOT submit claims for a code 88120 and 88121 professional component when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10 code