Avoid negative impacts to your claims -- review LCD L39073 and billing and coding article A58812 pharmacogenomics testing

Genetic testing holds the potential to provide great value in improving health outcomes for all individuals. The scope of this LCD includes testing to determine how genes affect the body's response to certain medicines, known as pharmacogenetic, or pharmacogenomic testing.

The LCD provides guidance on when pharmacogenetics testing will be considered medical reasonable and necessary, when it’s considered not medically necessary, the provider qualifications, the summary and analysis of evidence and FDA alerts. The billing and coding article provides guidance to the covered codes, limited coverage on certain codes, and codes that are non-covered. 

When billing Part B claims, the drug, or drugs in consideration for use that require the use of the PHARMACOGENOMICS (PGx) test must be submitted in the applicable detail line 2400 loop.

When more than two codes from the list within the billing and coding article are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list within the billing and coding article on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. Billing the 59 modifier may result in a request for medical records.

Be sure to review our article on documenting and billing genetic tests correctly for additional information. Claims inappropriately billed may be rejected or denied. Read the LCD L39073 and billing and coding article (A58812) in their entirety to make sure you’re billing and coding these services correctly.