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August 5, 2013

CYP2C9 and/or VKORC1 Gene Testing for Warfarin Response: Coding and Claim Submission Guidelines

These instructions are effective for dates of service on or after January 1, 2013.

Based on National Coverage Determination (NCD) 90.1 - Pharmacogenomic Testing for Warfarin Response, gene testing on CYP2C9 and/or VKORC1 will only be covered through coverage with evidence development (CED). Testing will be limited to once in a lifetime per beneficiary. CGS will reimburse only genetic testing services for beneficiaries who meet the NCD criteria and are enrolled in a clinical trial.

Lab providers that perform services on eligible beneficiaries described by CPT codes 81227 and 81355 must submit the following information on claims for gene testing for warfarin response:

  • HCPCS code: G9143- warfarin responsiveness testing
  • ICD-9-CM code: V70.7- Examination of patient in clinical trial
  • HCPCS modifier Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study

Note:

  1. Report only HCPCS code G9143 and 1 unit of service. Do not report CPT codes 81227 and/or 81355 on the claim.
  2. To facilitate payment, we strongly suggest that you submit the eight-digit clinical trial number:
    • Electronic claims: Loop 2400, NTE02, or SV101-7
    • Paper claims: Box 19
  3. References:

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