October 28, 2015
Pervenio Lung RS Assay Coding and Billing Guidelines (M00055)
MolDX has determined that the Pervenio Lung RS assay has insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the Pervenio service is a statutorily excluded service.
To receive a Pervenio service denial, please submit the following claim information:
- CPT code 81479 – unlisted molecular pathology procedure
- An Advance Beneficiary Notice of Non-Coverage (ABN)
is not required for statutorily excluded services.
- For a voluntary issued ABN, append with HCPCS modifier GX
- To indicate a valid ABN is on file for a known statutorily excluded service, append with HCPCS modifier GY
- Select the appropriate diagnosis for the patient
- Enter Z-Code Identifier™ adjacent to the CPT code in the comment/narrative field for the following claim field/types:
- Part A: Loop 2300 NTE 01 (electronic claim); Form Locator 80 (paper claim)
- Part B: Loop 2400 or SV101-7 (electronic claim); Item 19 (paper claim)
Reference: Sec. 1862 (1)(A) Statutory Exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,…"

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