Claims for Next Generation Sequencing May Have Been Denied in Error

Claims for Next Generation Sequencing May Have Been Denied in Error

Clinical diagnostic laboratories that fulfilled orders for targeted genomic sequence analysis panel CPT code 81455 between March 16, 2018, and March 31, 2018, may need to resubmit these claims to Medicare. Some claims may have been denied due to non-coverage for the given diagnosis.

However, since the Centers for Medicare & Medicaid Services (CMS) announced March 16, 2018, its decision to cover diagnostic laboratory tests using next generation sequencing (NCD 90.2 Next Generation Sequencing for Patients with Advanced Cancer), it has come to their attention that the list of allowable ICD-10-CM codes for 81455 was incorrect.

Transmittal 214, March 6, 2019, is rescinded and replaced with Transmittal 215, April 10, 2019, to incorporate the missing codes on the diagnosis code attachment.

The missing codes, effective 10/1/2018, are:

81455     Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

C43.111 Malignant melanoma of right upper eyelid, including canthus

C43.112 Malignant melanoma of right lower eyelid, including canthus

C43.121 Malignant melanoma of left upper eyelid, including canthus

C43.122 Malignant melanoma of left lower eyelid, including canthus

C44.1021 Unspecified malignant neoplasm of skin of right upper eyelid, including canthus

C44.1022 Unspecified malignant neoplasm of skin of right lower eyelid, including canthus

C44.1091 Unspecified malignant neoplasm of skin of left upper eyelid, including canthus

C44.1092 Unspecified malignant neoplasm of skin of left lower eyelid, including

C44.1121 Basal cell carcinoma of skin of right upper eyelid, including canthus

C44.1122 Basal cell carcinoma of skin of right lower eyelid, including canthus

C44.1191 Basal cell carcinoma of skin of left upper eyelid, including canthus

C44.1192 Basal cell carcinoma of skin of left lower eyelid, including canthus

C44.1221 Squamous cell carcinoma of skin of right upper eyelid, including canthus

C44.1222 Squamous cell carcinoma of skin of right lower eyelid, including canthus

C44.1291 Squamous cell carcinoma of skin of left upper eyelid, including canthus

C44.1292 Squamous cell carcinoma of skin of left lower eyelid, including canthus

C44.1921 Other specified malignant neoplasm of skin of right upper eyelid, including canthus

C44.1922 Other specified malignant neoplasm of skin of right lower eyelid, including canthus

C44.1991 Other specified malignant neoplasm of skin of left upper eyelid, including canthus

C44.1992 Other specified malignant neoplasm of skin of left lower eyelid, including canthus

C4A.111 Merkel cell carcinoma of right upper eyelid, including canthus

C4A.112 Merkel cell carcinoma of right lower eyelid, including canthus

C4A.121 Merkel cell carcinoma of left upper eyelid, including canthus

C4A.122 Merkel cell carcinoma of left lower eyelid, including canthus

Contractors are instructed to use CPT code 81455 for covered clinical diagnostic laboratory test FoundationOne CDx and this test’s respective allowed ICD-10 codes listed in Attachment 1 for claims with dates of service between March 16, 2018 and March 31, 2018.

CMS states in Transmittal 215 Change Request 10878:

“CMS is sensitive to the concerns of its stakeholders regarding the interpretation of this policy and will work with the MACs to adjust their respective claims processing systems accordingly. Thank you for your patience as we work through these outstanding issues.”


Sources:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R215NCD.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10878.pdf

Renee Dustman
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Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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