Gapfill Code Updates: CPT Code 81479, CPT Code 81225

NGS has released guidelines on the submission of Tier 2 codes and Warfarin (Coumadin) testing.. These tests involve the detection or identification of nucleic acid(s) (DNA/RNA), proteins, chromosomes, enzymes, cancer chemotherapy sensitivity, and/or other metabolite(s). 

• Tier 1 codes (CPT codes 81200-81383) are specific to one test and if reasonable and necessary and covered by the Medicare Program, may be priced for any claim using that code.
• Tier 2 codes (CPT codes 81400-81408) and CPT code 81479 represent multiple or unspecified tests, and each claim must be reviewed for medical necessity and for pricing by the contractor when billed.
  • To expedite processing of claims for Tier 2 codes and CPT 81479, the following information should be submitted with the claim, in the narrative field:

    The specific gene tested, a copy of the laboratory results, the patient’s diagnosis code, and clinical information from the ordering physician that supports the medical necessity of the test rendered.

Special instructions for CPT 81225, CPT 81226, CPT 81227, or CPT 81355: Per a national CMS requirement, these codes cannot be used for Warfarin (Coumadin) testing. Only G9143 with the Q0 modifier must be used and the service must be in a “coverage with evidence development (CED)” trial. The existence of a molecular diagnostic test and code does not necessarily mean that the test meets medical necessity criteria in the clinical environment. Federal law requires that the testing be used to treat the specific Medicare beneficiary and not be of a screening nature.

MAC J13 for the states of Connecticut and New York
MAC J6 for Wisconsin, Illinois, and Minnesota
MAC JK for Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont