August 17, 2015 - Updated 11.29.16
CGS Administrators Announces MolDX Expansion to J15 (Vol 2)
CGS Administrators is happy to announce that we are working with the MolDx contractor, Palmetto GBA concerning Molecular Diagnostic Testing (MDT). All laboratory service providers in the Jurisdiction 15 providing Molecular Diagnostic Testing (MDT) must register those MDT procedures/services with the MolDx contractor and submit coverage requests prior to being considered for reimbursement. Providers will have until December 28, 2015 to complete this process for current and any new tests billed before the claim is returned unable to process if the unique identifier is not present on the claim. At this time, Part A providers are not required but are encouraged to obtain an identifier and use the TA process, if needed, as this will expedite claims processing. Part A providers when billing MolDx tests, since the notepad is for the entire claim please, please enter L, line number, and the short description /identifier,(L2-APC,fgs). This will allow us to distinguish which test is for which line. .(Effective March 1, 2017 Part A providers will need to bill MolDX codes with a Z-identifier in addtion to billing the CPT code. Providers who submit to Part A please see the Part A MolDX Claim Submission Instructions CM00098 article.)
As a CMS contractor, the MolDx contractor must determine reasonable and necessary services and apply fair reimbursement to services that are provided to Medicare beneficiaries. In the AMA's instructions for use of the CPT codebook, providers are instructed to select the name of the procedure/service that accurately identifies the service provided. Providers are not to select a CPT code that merely approximates the service provided. When no such specific code exists, providers are required to report the service using the appropriate unlisted procedure/service code.
For a wide range of laboratory and molecular diagnostic services, correct coding is complicated because the available code descriptions do not identify the specific test/service performed.
The vast numbers of new diagnostic and molecular assays entering the market magnify these issues. To address these vulnerabilities, the MolDx contractor has expanded to a laboratory and molecular diagnostic services program to meet the following objectives:
This program will affect diagnostic services reported with the following AMA © CPT codes:
Effective for services performed on or after January 1, 2013
For services performed prior to 01/01/13:
MolDx defines a clear, evidence-based process to ensure clinical quality and manage molecular diagnostic services and the associated impact that they have on cost.
Four major challenges are addressed in this project:
The project will require a registration process to address these challenges in the following manner:
MolDx will be supported by the LCD Laboratory and Molecular Diagnostics Testing LCD Program, establishes a clear, evidence-based process to ensure clinical quality and to manage molecular diagnostic services and the associated healthcare cost impact. The MolDx contractor has contracted with McKesson Health Solutions to configure and maintain a Master Test Code Registry that will increase the efficiency and transparency of the evaluation and valuation of the affected procedures/assays.
For more information, please refer to the MolDx contractor website.
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