October 5, 2015
Chimerism Testing Billing and Coding Guidelines (CM00020)
Chimerism analysis, reported with CPT codes 81265-81268, to identify appropriate donors and monitor engraftment success or disease reoccurrence is a covered Medicare service.
CPT code 81265 includes donor and recipient testing and should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.
CPT code 81266 describes a service that may be used for two different reasons: additional births and bone marrow transplant. When used in bone marrow transplants to report an additional double-cord blood sample, it is a covered service. Since its use to report multiple births would be atypical for the Medicare population, it would not be a covered service.
CPT code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, CPT code 81265 should not be submitted in addition to CPT code 81267. For labs that hold the pre-transplant specimen (CPT codes 81265 and/or 81266) until after the transplant occurs, use CPT codes 81267, plus 81265 and 81266, if necessary.
Note: CPT code 81267 should be reported for the findings of the pre and post-transplant comparison.
CPT code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (CPT codes 81265 and/or 81266) until after the transplant occurs, use CPT codes 81267, plus 81265 and 81266, if necessary.
MolDX would not expect to see a claim for CPT code 81265 pre-transplant and an additional CPT code 81265 and CPT code 81267 post-transplant, or a claim for CPT code 81265 pre-transplant and an additional claim for CPT code 81268.
Exceptions: Although the initial chimerism testing, CPT code 81265, for engraftment is usually limited to once in a lifetime, MolDX recognizes special circumstances may require an additional service and will consider approval on a case-by-case basis through the appeal process.
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