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October 12, 2015 - Revised 08.11.17

ResponseDX Tissue of Origin® Coding and Billing Guidelines (CM00030, V4)

Tissue of Origin®, a microarray - based gene expression assay, was designed to determine the similarity of unknown or unresolved tumors to cancers from 1 of 15 known tumors of origin.

To bill for Tissue of Origin services, please provide the following claim information:

  • Claims received on and after 1/1/2015: CPT code 81504 - Oncology (tissue of origin)
  • Enter '1' in the Days/Unit field

Enter Z - Code IdentifierTM in the comment/narrative field for the following claim field/types:

  • Loop 2300 NTE01/SV202-7 for Part A or SV101-7 field for Part B
  • Submit DEX Z - Code™ Identifier on an attachment to the claim form for paper claim (Form locator 80 for Part A or Box 19 for Part B)

Select the Appropriate ICD-10-CM diagnoses:

  • C18.1 - Malignant neoplasm of appendix
  • C18.9 – Malignant neoplasm of colon, unspecified
  • C22.0 - Liver cell carcinoma
  • C22.2 – Hepatoblastoma
  • C22.3 – Angiosarcoma of liver
  • C22.4 – Other Sarcomas of liver
  • C22.7 – Other specified carcinomas of liver
  • C22.8 – Malignant neoplasm of liver, primary, unspecified as to type
  • C22.9 – Malignant neoplasm of liver, not specified as primary or secondary
  • C25.2 – Malignant neoplasm of tail of pancreas
  • C25.7 – Malignant neoplasm of other parts of the pancreas
  • C25.8 – Malignant neoplasm of overlapping sites of pancreas
  • C25.9 – Malignant neoplasm of pancreas, unspecified
  • C33 – Malignant neoplasm of trachea
  • C34.00 – Malignant neoplasm of unspecified main bronchus
  • C34.01 – Malignant neoplasm of right main bronchus
  • C34.02 – Malignant neoplasm of left main bronchus
  • C34.10 – Malignant neoplasm of upper lobe, unspecified bronchus or lung
  • C34.11 – Malignant neoplasm of upper lobe, right bronchus or lung
  • C34.12 - Malignant neoplasm of upper lobe, left bronchus or lung
  • C34.30 – Malignant neoplasm of lower lobe, unspecified bronchus or lung
  • C34.31 – Malignant neoplasm of lower lobe, right bronchus or lung
  • C34.32 – Malignant neoplasm of lower lobe, left bronchus or lung
  • C34.80 – Malignant neoplasm of overlapping sites of unspecified bronchus and lung
  • C34.81 – Malignant neoplasm of overlapping sites of right bronchus and lung
  • C43.51 – Malignant melanoma of anal skin
  • C43.52 – Malignant melanoma of skin of breast
  • C43.59 – Malignant melanoma of other part of trunk
  • C45.9 – Mesothelioma, unspecified
  • C47.0 – Malignant neoplasm of peripheral nerves of head, face, and neck
  • C47.9 – Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified
  • C48.0 – Malignant neoplasm of retroperitoneum
  • C49.0 Malignant neoplasm of connective and soft tissue of head, face, and neck
  • C49.9 – Malignant neoplasm of connective and soft tissue, unspecified
  • C50.411 – Malignant neoplasm of upper - outer quadrant of right female breast
  • C50.419 – Malignant neoplasm of upper - outer quadrant of left female breast
  • C50.419 – Malignant neoplasm of upper - outer quadrant of unspecified female breast
  • C50.511 – Malignant neoplasm of lower - outer quadrant of right female breast
  • C50.512 – Malignant neoplasm of lower - outer quadrant of left female breast
  • C50.519 – Malignant neoplasm of lower - outer quadrant of unspecified female breast
  • C50.811 – Malignant neoplasm of overlapping sites of right female breast
  • C50.812 – Malignant neoplasm of overlapping sites of left female breast
  • C50.819 – Malignant neoplasm of overlapping sites of unspecified female breast
  • C50.911 – Malignant neoplasm of unspecified site of right female breast
  • C50.912 – Malignant neoplasm of unspecified site of left female breast
  • C50.919 – Malignant neoplasm of unspecified site of unspecified female breast
  • C56.1 – Malignant neoplasm of right ovary
  • C56.2 – Malignant neoplasm of left ovary
  • C56.9 – Malignant neoplasm of unspecified ovary
  • C61 – Malignant neoplasm of prostate
  • C64.1 – Malignant neoplasm of right kidney, except renal pelvis
  • C64.2 –Malignant neoplasm of left kidney, expect renal pelvis
  • C64.9 – Malignant neoplasm of unspecified kidney, except renal pelvis
  • C67.5 – Malignant neoplasm of bladder neck
  • C67.9 – Malignant neoplasm of bladder, unspecified
  • C76.0 Malignant neoplasm of head, face and neck
  • C77.0 – Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
  • C77.1 – Secondary and unspecified malignant neoplasm of intrapelvia lymph nodes
  • C77.2 – Secondary and unspecified malignant neoplasm of intra - abdominal lymph nodes
  • C77.3 – Secondary unspecified malignant neoplasm of axilla and upper limb lymph nodes
  • C77.4 – Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes
  • C77.5 – Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes
  • C77.8 – Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions
  • C77.9 – Secondary and unspecified malignant neoplasm of lymph node, unspecified
  • C78.00 – Secondary and unspecified malignant neoplasm of unspecified lung
  • C78.01 – Secondary malignant neoplasm of right lung
  • C78.02 – Secondary malignant neoplasm of left lung
  • C78.5 – Secondary malignant neoplasm of large intestine and rectum
  • C78.6 – Secondary malignant neoplasm of retroperitoneum and peritoneum
  • C78.7 – Secondary malignant neoplasm of liver and intrahepatic bile duct
  • C79.00 – Secondary malignant neoplasm of unspecified kidney and renal pelvis
  • C79.01 – Secondary malignant neoplasm of right kidney and renal pelvis
  • C79.02 – Secondary malignant neoplasm of left kidney and renal pevis
  • C79.2 – Secondary malignant neoplasm of skin
  • C79.31 – Secondary malignant neoplasm of brain
  • C79.51 – Secondary malignant neoplasm of bone
  • C79.52 – Secondary malignant neoplasm of bone marrow
  • C79.60 – Secondary malignant neoplasm of unspecified ovary
  • C79.61 – Secondary malignant neoplasm of right ovary
  • C79.62 – Secondary malignant neoplasm of left ovary
  • C79.89 – Secondary malignant neoplasm of other specified sites
  • C79.9 – Secondary malignant neoplasm of unspecified site
  • C80.0 – Disseminated malignant neoplasm, unspecified
  • C80.1 – Malignant (primary) neoplasm, unspecified
  • C82.57 – Diffuse follicle center lymphoma, spleen
  • C84.97 – Mature T/NK - cell lymphomas, unspecified, spleen
  • C84.A7 – Cutaneous T - cell lymphoma, unspecified, spleen
  • C85.17 – Unspecified B - cell lymphoma, spleen
  • C85.27 – Mediastinal (thymic) large B - cell lymphoma, spleen
  • C85.87 – Other specified types of non - Hodgkin lymphoma, spleen
  • C85.97 – Non - Hodgkin lymphoma, unspecified spleen
  • C86.1 – Hepatosplenic T - cell lymphoma
  • D01.5 – Carcinoma in situ of liver, gallbladder and bile ducts
  • D01.7 - Carcinoma in situ of other specified digestive oragans
  • D01.9 - Carcinoma in situ of od digestive organ, unspecified
  • D02.20 - Carcinoma in situ of unspecified bronchus and lung
  • D02.21 – Carcinoma in situ of right bronchus and lung
  • D02.22 - Carcinoma in situ of left bronchus and lung
  • D03.51 - Melanoma in situ of anal skin
  • D03.52 - Melanoma in situ of breast (skin) (soft tissue)
  • D03.59 – Melanoma in situ of other part of trunk
  • D49.0 – Neoplasm of unspecified behavior of digestive system
  • D49.1 – Neoplasm of unspecified behavior of respiratory system
  • D49.2 – Neoplasm of unspecified behavior of bone, soft tissue, and skin
  • D49.3 – Neoplasm of unspecified behavior of breast
  • D49.511-Neoplasm of unspecified behavior of right kidney
  • D49.512-Neoplasm of unspecified behavior of left kidney
  • D49.4 – Neoplasm of unspecified behavior of other genitourinary organs
  • D49.6 – Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
  • D49.89 – Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
  • D49.9 – Neoplasm of unspecified behavior of unspecified sites
  • J91.0 – Malignant pleural effusion

This test is to be ordered ONLY by the treating physician.

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