Order # CPT Estimated Fee
ALDH7A2 Sequence Analysis (MRLT) 81406
Ashkenazi Jewish (BRCA1 and BRCA2) 3
Mutations 47300 81212 $650.00
BCR/ABL Gene Detection, Qualitative PCR,
Diagnostic Assay 36149 81206; 81207 $820.50
BCR/ABL Gene Major Breakpoint (p210),
Quantitative PCR, Monitoring Assay 36145 81206 $802.90
BCR-ABL1 Mutation Analysis, Next Generation
Sequencing 47105 81403 $1,243.90
BRAF Mutation Analysis 36273 81210 $600.00
Breast and Ovarian Hereditary Cancer Syndrome
(BRCA1 and BRCA2) Sequencing 47298 81211 $4,090.00
Breast and Ovarian Hereditary Cancer Syndrome (BRCA1 and BRCA2) Sequencing and
Deletion/Duplication
47297 81211; 81213 $3,100.00
Breast and Ovarian Hereditary Cancer Syndrome
(BRCA1 and BRCA2) Deletion/Duplication 47299 81213 $990.00
Cytochrome P450 2D6 (CYP2D6), 14 Variants
and Gene Duplication 45288 81226 $800.00
EGFR Mutation Analysis 36275 81235 $600.00
Familial Mutation, Targeted Sequencing 45867
See TMF Lab Manual for complete listing
$500.00
Galactosemia (GALT), Sequencing 47279 81406 $1,500.00
Hereditary Hemorrhagic Telangiectasia (ACVRL1
and ENG) Deletion/Duplication 44946 81405; 81479 $1,012.80
Hereditary Hemorrhagic Telangiectasia (ACVRL1
and ENG) Sequencing 44947 81406 $2,400.00
Hereditary Hemorrhagic Telangiectasia (ACVRL1
and ENG) Sequencing and Deletion/Duplication 44945 81405; 81406;
81479x2 $3,412.80 HLA-B*5701 Associated Variant Genotyping for
Abacavir Sensitivity 44877 81381 $320.00
HNPCC/Lynch Syndrome (MLH1) Sequencing
and Deletion/Duplication 44934 81292; 81294 $2,700.00
HNPCC/Lynch Syndrome (MSH2) Sequencing
and Deletion/Duplication 44930 81295; 81297 $2,700.00
HNPCC/Lynch Syndrome (MSH6) Sequencing
and Deletion/Duplication 44931 81298; 81300 $2,700.00
HNPCC/Lynch Syndrome (PMS2) Sequencing and Deletion/Duplication, with Reflex to Pseudogene Analysis
44933 81317; 81319 $2,800.00
JAK2 (V617F) Mutation Analysis 36140 81270 $362.90
JAK2 Exon 12 and Other Non-V617F Mutation
Detection, Blood 42317 81403 $598.00
KRAS Mutation Analysis 36272 81275 $600.00
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Legius Syndrome (SPRED1) Sequencing 44954 81405 $927.00 MAPT Gene, Sequence Analysis, 7 Exon
Screening Panel 42347 81406 $945.75
Microsatellite Instability (MSI) by PCR 38547 81301 Mismatch Repair (MMR) Analysis by
Immunohistochemistry (IHC) 38520 88342
88341x3
Mitochondrial Disorders (108 Nuclear Genes)
Sequencing 45889
Mitochondrial Genome (mtDNA and 108 Nuclear
Genes) Deletion/Duplication 45888
81404x3;
81405x2;
81406; 81465;
81479
$2,200.00
Mitochondrial Disorders Panel (mtDNA and 108 Nuclear Genes) Sequencing and
Deletion/Duplication
Multiple Endocrine Neoplasia Type 1 (MEN1)
Sequencing 45945 81405 $1,340.00
Multiple Endocrine Neoplasia Type 1 (MEN1)
Sequencing and Deletion/Duplication 45946 81404/81405 Multiple Endocrine Neoplasia Type 2 (MEN2),
RET Gene Mutations, Sequencing 45400 81405 $1,200.00
Noonan Syndrome (PTPN11) Sequencing 45764 81406 $2,400.00
Noonan Syndrome (PTPN11) Sequencing with
Reflex to (SOS1) Sequencing 45765 81406 $2,400.00
Noonan Syndrome (SOS1) Sequencing 45766 81406 $2,300.00
Red Blood Cell Antigen Phenotype, Molecular
Analysis 36174 81403 $550.00
Very Long-Chain Acyl-CoA Dehydogenase
Deficiency (ACADVL) Sequencing 45715 81406 $1,980.00
Very Long-Chain Acyl-CoA Dehydrogenase Deficiency (ACADVL) Sequencing and Deletion/Duplication
45717 81406/81479 $3,020.00
Von Hippel-Lindau (VHL) Deletion/Duplication 45873 81403 $800.00
Wilson Disease (ATP7B) Sequencing 47172 81406 $2,300.00
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY AND DO NOT CURRENTLY REQUIRE AN ABN: Group 1 Paragraph: CPT codes 81201, 81202, 81203 81210, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, and 81403, 81405, 81406 (that meet coverage criteria as indications for testing for lynch syndrome).
V12.72 should be used to denote any of the polyposis conditions as described under Indications and Limitations section.
81210 will also be covered for 172.0-172.9
151.0 - 151.6 Malignant Neoplasm Of Cardia - Malignant Neoplasm Of Greater Curvature Of Stomach Unspecified
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151.8 Malignant Neoplasm Of Other Specified Sites Of Stomach 151.9 Malignant Neoplasm Of Stomach Unspecified Site
152.0 - 152.3 Malignant Neoplasm Of Duodenum - Malignant Neoplasm Of Meckel's Diverticulum 152.8 Malignant Neoplasm Of Other Specified Sites Of Small Intestine
152.9 Malignant Neoplasm Of Small Intestine Unspecified Site 153.0 Malignant Neoplasm Of Hepatic Flexure
153.1 Malignant Neoplasm Of Transverse Colon 153.2 Malignant Neoplasm Of Descending Colon 153.3 Malignant Neoplasm Of Sigmoid Colon 153.4 Malignant Neoplasm Of Cecum
153.5 Malignant Neoplasm Of Appendix Vermiformis 153.6 Malignant Neoplasm Of Ascending Colon 153.7 Malignant Neoplasm Of Splenic Flexure
153.8 Malignant Neoplasm Of Other Specified Sites Of Large Intestine 153.9 Malignant Neoplasm Of Colon Unspecified Site
154.0 Malignant Neoplasm Of Rectosigmoid Junction 154.1 Malignant Neoplasm Of Rectum
154.2 Malignant Neoplasm Of Anal Canal
154.3 Malignant Neoplasm Of Anus Unspecified Site
154.8 Malignant Neoplasm Of Other Sites Of Rectum Rectosigmoid Junction And Anus
155.0 - 155.2 Malignant Neoplasm Of Liver Primary - Malignant Neoplasm Of Liver Not Specified As Primary Or Secondary
156.1 Malignant Neoplasm Of Extrahepatic Bile Ducts
156.9 Malignant Neoplasm Of Biliary Tract Part Unspecified Site
157.0 - 157.4 Malignant Neoplasm Of Head Of Pancreas - Malignant Neoplasm Of Islets Of Langerhans 157.8 Malignant Neoplasm Of Other Specified Sites Of Pancreas
157.9 Malignant Neoplasm Of Pancreas Part Unspecified 158.8 Malignant Neoplasm Of Specified Parts Of Peritoneum 158.9 Malignant Neoplasm Of Peritoneum Unspecified
172.0 - 172.9* Malignant Melanoma Of Skin Of Lip - Melanoma Of Skin Site Unspecified 179 Malignant Neoplasm Of Uterus-Part Uns
182.0 Malignant Neoplasm Of Corpus Uteri Except Isthmus 182.1 Malignant Neoplasm Of Isthmus
182.8 Malignant Neoplasm Of Other Specified Sites Of Body Of Uterus 183.0 Malignant Neoplasm Of Ovary
183.2 - 183.5 Malignant Neoplasm Of Fallopian Tube - Malignant Neoplasm Of Round Ligament Of Uterus 183.8 Malignant Neoplasm Of Other Specified Sites Of Uterine Adnexa
183.9 Malignant Neoplasm Of Uterine Adnexa Unspecified Site
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189.0 - 189.2 Malignant Neoplasm Of Kidney Except Pelvis - Malignant Neoplasm Of Ureter 189.8 Malignant Neoplasm Of Other Specified Sites Of Urinary Organs
191.0 - 191.9 Malignant Neoplasm Of Cerebrum Except Lobes And Ventricles - Malignant Neoplasm Of Brain Unspecified Site
197.5 Secondary Malignant Neoplasm Of Large Intestine And Rectum
V10.00 Personal History Of Malignant Neoplasm Of Unspecified Site In Gastrointestinal Tract V10.05 Personal History Of Malignant Neoplasm Of Large Intestine
V10.06 Personal History Of Malignant Neoplasm Of Rectum Rectosigmoid Junction And Anus V10.42 Personal History Of Malignant Neoplasm Of Other Parts Of Uterus
V10.43 Personal History Of Malignant Neoplasm Of Ovary V10.53 Personal History Of Malignant Neoplasm Of Renal Pelvis
V10.59 Personal History Of Malignant Neoplasm Of Other Urinary Organs V10.85 Personal History Of Malignant Neoplasm Of Brain
V12.72 Personal History Of Colonic Polyps Group 2 Paragraph: 81301
153.0 - 153.9 Malignant Neoplasm Of Hepatic Flexure - Malignant Neoplasm Of Colon Unspecified Site V10.05 Personal History Of Malignant Neoplasm Of Large Intestine
V10.06 Personal History Of Malignant Neoplasm Of Rectum Rectosigmoid Junction And Anus V10.42 Personal History Of Malignant Neoplasm Of Other Parts Of Uterus
V16.0 Family History Of Malignant Neoplasm Of Gastrointestinal Tract V84.04 Genetic Susceptibility To Malignant Neoplasm Of Endometrium V84.09 Genetic Susceptibility To Other Malignant Neoplasm
Group 3 Paragraph: CPT codes 81211, 81212, 81213, 81214, 81215 and 81217 and meet the coverage criteria for BRCA1 and BRCA2 gene mutation testing.
Group 3 Codes:
158.0 Malignant Neoplasm Of Retroperitoneum
158.8 Malignant Neoplasm Of Specified Parts Of Peritoneum 174.0 Malignant Neoplasm Of Nipple And Areola Of Female Breast 174.1 Malignant Neoplasm Of Central Portion Of Female Breast 174.2 Malignant Neoplasm Of Upper-Inner Quadrant Of Female Breast 174.3 Malignant Neoplasm Of Lower-Inner Quadrant Of Female Breast 174.4 Malignant Neoplasm Of Upper-Outer Quadrant Of Female Breast 174.5 Malignant Neoplasm Of Lower-Outer Quadrant Of Female Breast 174.6 Malignant Neoplasm Of Axillary Tail Of Female Breast
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174.8 Malignant Neoplasm Of Other Specified Sites Of Female Breast 174.9 Malignant Neoplasm Of Breast (Female) Unspecified Site 175.0 Malignant Neoplasm Of Nipple And Areola Of Male Breast
175.9 Malignant Neoplasm Of Other And Unspecified Sites Of Male Breast 183.0 Malignant Neoplasm Of Ovary
183.2 Malignant Neoplasm Of Fallopian Tube 233.0 Carcinoma In Situ Of Breast
V10.3 Personal History Of Malignant Neoplasm Of Breast V10.43 Personal History Of Malignant Neoplasm Of Ovary
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Group 4 Paragraph: CPT 81235
Group 4 Codes:
162.0 - 162.9 Malignant Neoplasm Of Trachea - Malignant Neoplasm Of Bronchus And Lung Unspecified 163.0 - 163.9 Malignant Neoplasm Of Parietal Pleura - Malignant Neoplasm Of Pleura Unspecified
Group 5 Paragraph: CPT codes 81270 and 81403 (that meet coverage criteria for JAK2 testing).
Group 5 Codes:
204.00 Acute Lymphoid Leukemia, Without Mention Of Having Achieved Remission 204.10 Chronic Lymphoid Leukemia, Without Mention Of Having Achieved Remission 204.11 Lymphoid Leukemia Chronic In Remission
204.12 Chronic Lymphoid Leukemia, In Relapse
205.00 Acute Myeloid Leukemia, Without Mention Of Having Achieved Remission 205.10 Chronic Myeloid Leukemia, Without Mention Of Having Achieved Remission 238.4 Polycythemia Vera
238.71 Essential Thrombocythemia
238.75 Myelodysplastic Syndrome, Unspecified 238.76 Myelofibrosis With Myeloid Metaplasia 238.79 Other Lymphatic And Hematopoietic Tissues 238.9 Neoplasm Of Uncertain Behavior Site Unspecified 288.51 Lymphocytopenia
288.61 Lymphocytosis (Symptomatic)
288.8 Other Specified Disease Of White Blood Cells 453.0 Budd-Chiari Syndrome
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