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CMS Transmittals




81161
Quick jump to procedure code: Printer Friendly Version
81163

Procedure Category: Pathology and Laboratory
Procedure Subcategory: Tier 1 Molecular Pathology Procedures

81162: BRCA1&2 GEN FULL SEQ DUP/DEL

CPT® 81162: BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)



--

CPT copyright 2018 American Medical Association. All rights reserved.


Medicare Reimbursement Information         Hide this section.

Unadjusted-National Fee Schedule Amount
ALABAMA-Entire State
ALASKA-Entire State
ARIZONA-Entire State
ARKANSAS-Entire State
CALIFORNIA NORTH-Napa
CALIFORNIA NORTH-San Francisco
CALIFORNIA NORTH-San Mateo
CALIFORNIA NORTH-Oakland/Berkeley
CALIFORNIA NORTH-Santa Clara
CALIFORNIA NORTH-Yuba City
CALIFORNIA NORTH-San Francisco/Oakland/Hayward (Marin County)
CALIFORNIA NORTH-Vallejo/Fairfield
CALIFORNIA NORTH-Bakersfield
CALIFORNIA NORTH-Chico
CALIFORNIA NORTH-Fresno
CALIFORNIA NORTH-Hanford/Corcoran
CALIFORNIA NORTH-Madera
CALIFORNIA NORTH-Merced
CALIFORNIA NORTH-Modesto
CALIFORNIA NORTH-Redding
CALIFORNIA NORTH-Riverside/San Bernardino/Ontario
CALIFORNIA NORTH-Sacramento/Roseville/Arden/Arcade
CALIFORNIA NORTH-Salinas
CALIFORNIA NORTH-San Jose/Sunnyvale/Santa Clara (San Benito County)
CALIFORNIA NORTH-Santa Cruz/Watsonville
CALIFORNIA NORTH-Santa Rosa
CALIFORNIA NORTH-Stockton/Lodi
CALIFORNIA NORTH-Visalia/Porterville
CALIFORNIA SOUTH-Ventura
CALIFORNIA SOUTH-Los Angeles
CALIFORNIA SOUTH-Anaheim/Santa Ana
CALIFORNIA SOUTH-El Centro
CALIFORNIA SOUTH-San Diego/Carlsbad
CALIFORNIA SOUTH-San Luis Obispo/Paso Robles/Arroyo Grande
CALIFORNIA SOUTH-Santa Maria/Santa Barbara
COLORADO-Entire State
CONNECTICUT-Entire State
DELAWARE-Entire State
DIST of COL-DC + MD/VA Suburbs
FLORIDA-Ft Lauderdale
FLORIDA-Miami
FLORIDA-Rest of Florida
GEORGIA-Atlanta
GEORGIA-Rest of Georgia
HAWAII/GUAM-Entire State/Terr.
IDAHO-Entire State
ILLINOIS-East St. Louis
ILLINOIS-Suburban Chicago
ILLINOIS-Chicago
ILLINOIS-Rest of Illinois
INDIANA-Entire State
IOWA-Entire State
KANSAS-Entire State
KENTUCKY-Entire State
LOUISIANA-New Orleans
LOUISIANA-Rest of Louisiana
MAINE-Southern Maine
MAINE-Rest of Maine
MARYLAND-Baltimore and suburbs
MARYLAND-Rest of Maryland
MASSACHUSETTS-Boston
MASSACHUSETTS-Rest of Massachusetts
MICHIGAN-Detroit
MICHIGAN-Rest of Michigan
MINNESOTA-Entire State
MISSISSIPPI-Entire State
MISSOURI-Kansas City
MISSOURI-St. Louis
MISSOURI-Rest of Missouri
MONTANA-Entire State
NEBRASKA-Entire State
NEVADA-Entire State
NEW HAMPSHIRE-Entire State
NEW JERSEY-Northern NJ
NEW JERSEY-Rest of New Jersey
NEW MEXICO-Entire State
NEW YORK-Manhattan
NEW YORK-NYC Suburbs/LI
NEW YORK-Poughkpsie/No NYC Sub
NEW YORK-Rest of New York
NEW YORK-Queens
NORTH CAROLINA-Entire State
NORTH DAKOTA-Entire State
OHIO-Entire State
OKLAHOMA-Entire State
OREGON-Portland
OREGON-Rest of Oregon
PENNSYLVANIA-Philadelphia
PENNSYLVANIA-Rest of Pennsylvania
PUERTO RICO-Entire Territory
RHODE ISLAND-Entire State
SOUTH CAROLINA-Entire State
SOUTH DAKOTA-Entire State
TENNESSEE-Entire State
TEXAS-Brazoria
TEXAS-Dallas
TEXAS-Galveston
TEXAS-Houston
TEXAS-Beaumont
TEXAS-Fort Worth
TEXAS-Austin
TEXAS-Rest of Texas
UTAH-Entire State
VERMONT-Entire State
VIRGIN ISLANDS-Entire State
VIRGINIA-Entire State
WASHINGTON-Seattle (King County)
WASHINGTON-Rest of Washington
WEST VIRGINIA-Entire State
WISCONSIN-Entire State
WYOMING-Entire State
2019 Laboratory Fee Schedule: $2027.64


2019A OPPS Status Indicator: A

Effective April 1, 2013, and while sequestration is in effect, all CMS payments for services will be reduced by 2%. The fees above do not reflect this reduction. Click here for more information.

Commonly Associated Diagnosis Codes*            Hide this section.
Percentage
ICD-10 Code
Description
Related DRG(s)
30.4%
Z85.3
Personal history of malignant neoplasm of breast
826-830
843-845
23.4%
C50.919
Malignant neoplasm of unspecified site of unspecified female breast
582-583
597-601
6.0%
C56.9
Malignant neoplasm of unspecified ovary
736-741
754-756
4.0%
Z85.43
Personal history of malignant neoplasm of ovary
826-830
843-845
4.0%
Z80.3
Family history of malignant neoplasm of breast
951
2.3%
D05.11
Intraductal carcinoma in situ of right breast
582-583
597-601
2.0%
C50.912
Malignant neoplasm of unspecified site of left female breast
582-583
597-601
2.0%
C50.411
Malignant neoplasm of upper-outer quadrant of right female breast
582-583
597-601
1.7%
C50.929
Malignant neoplasm of unspecified site of unspecified male breast
582-583
597-601
1.7%
N63
This diagnosis code is no longer active.
597-601

* Commonly Associated ICD-10 codes derived from CMS Q3 2016 Limited Data Set (LDS) claims data.
This data represents an analysis of 11,119,991 claims processed for 1,414,138 beneficiaries in the third quarter of 2016.

Medicare Coverage Policy Information         Hide this section.
No contractor selected.

81162 not found in an Local Coverage Determination (LCD) for your contractor. Other contractors covering 81162

CCI and MUE Edits*         Hide this section.

Multiple Code CCI/MUE Edit Report-New

Column 1 CCI Edits for 81162
Denied Codes (1)
Effective
Modifier
Accepted (2)
0009U ONC BRST CA ERBB2 AMP/NONAMP
01/01/2018 Yes
0500T HPV 5+ HI RISK HPV TYPES
01/01/2018 Yes
80500 LAB PATHOLOGY CONSULTATION
04/01/2017 Yes
80502 LAB PATHOLOGY CONSULTATION
04/01/2017 Yes
81163 BRCA1&2 GENE FULL SEQ ALYS
01/01/2019 No
81164 BRCA1&2 GEN FUL DUP/DEL ALYS
01/01/2019 No
81165 BRCA1 GENE FULL SEQ ALYS
01/01/2019 No
81166 BRCA1 GENE FULL DUP/DEL ALYS
01/01/2019 No
81167 BRCA2 GENE FULL DUP/DEL ALYS
01/01/2019 No
81216 BRCA2 GENE FULL SEQ ALYS
01/01/2016 No
84311 SPECTROPHOTOMETRY
01/01/2016 Yes
87140 CULTURE TYPE IMMUNOFLUORESC
01/01/2016 Yes
87143 CULTURE TYPING GLC/HPLC
01/01/2016 Yes
87147 CULTURE TYPE IMMUNOLOGIC
01/01/2016 Yes
87149 DNA/RNA DIRECT PROBE
01/01/2016 Yes
87150 DNA/RNA AMPLIFIED PROBE
01/01/2016 Yes
87152 CULTURE TYPE PULSE FIELD GEL
01/01/2016 Yes
87153 DNA/RNA SEQUENCING
01/01/2016 Yes
87158 CULTURE TYPING ADDED METHOD
01/01/2016 Yes
87471 BARTONELLA DNA AMP PROBE
01/01/2016 Yes
87472 BARTONELLA DNA QUANT
01/01/2016 Yes
87475 LYME DIS DNA DIR PROBE
01/01/2016 Yes
87476 LYME DIS DNA AMP PROBE
01/01/2016 Yes
87480 CANDIDA DNA DIR PROBE
01/01/2016 Yes
87481 CANDIDA DNA AMP PROBE
01/01/2016 Yes
87482 CANDIDA DNA QUANT
01/01/2016 Yes
87483 CNS DNA AMP PROBE TYPE 12-25
01/01/2017 Yes
87485 CHYLMD PNEUM DNA DIR PROBE
01/01/2016 Yes
87486 CHYLMD PNEUM DNA AMP PROBE
01/01/2016 Yes
87487 CHYLMD PNEUM DNA QUANT
01/01/2016 Yes
87490 CHYLMD TRACH DNA DIR PROBE
01/01/2016 Yes
87491 CHYLMD TRACH DNA AMP PROBE
01/01/2016 Yes
87492 CHYLMD TRACH DNA QUANT
01/01/2016 Yes
87493 C DIFF AMPLIFIED PROBE
01/01/2016 Yes
87495 CYTOMEG DNA DIR PROBE
01/01/2016 Yes
87496 CYTOMEG DNA AMP PROBE
01/01/2016 Yes
87497 CYTOMEG DNA QUANT
01/01/2016 Yes
87498 ENTEROVIRUS PROBE&REVRS TRNS
01/01/2016 Yes
87500 VANOMYCIN DNA AMP PROBE
01/01/2016 Yes
87501 INFLUENZA DNA AMP PROB 1+
01/01/2016 Yes
87502 INFLUENZA DNA AMP PROBE
01/01/2016 Yes
87503 INFLUENZA DNA AMP PROB ADDL
01/01/2016 Yes
87505 NFCT AGENT DETECTION GI
01/01/2016 Yes
87506 IADNA-DNA/RNA PROBE TQ 6-11
01/01/2016 Yes
87507 IADNA-DNA/RNA PROBE TQ 12-25
01/01/2016 Yes
87510 GARDNER VAG DNA DIR PROBE
01/01/2016 Yes
87511 GARDNER VAG DNA AMP PROBE
01/01/2016 Yes
87512 GARDNER VAG DNA QUANT
01/01/2016 Yes
87516 HEPATITIS B DNA AMP PROBE
01/01/2016 Yes
87517 HEPATITIS B DNA QUANT
01/01/2016 Yes
87520 HEPATITIS C RNA DIR PROBE
01/01/2016 Yes
87521 HEPATITIS C PROBE&RVRS TRNSC
01/01/2016 Yes
87522 HEPATITIS C REVRS TRNSCRPJ
01/01/2016 Yes
87525 HEPATITIS G DNA DIR PROBE
01/01/2016 Yes
87526 HEPATITIS G DNA AMP PROBE
01/01/2016 Yes
87527 HEPATITIS G DNA QUANT
01/01/2016 Yes
87528 HSV DNA DIR PROBE
01/01/2016 Yes
87529 HSV DNA AMP PROBE
01/01/2016 Yes
87530 HSV DNA QUANT
01/01/2016 Yes
87531 HHV-6 DNA DIR PROBE
01/01/2016 Yes
87532 HHV-6 DNA AMP PROBE
01/01/2016 Yes
 
Denied Codes (1)
Effective
Modifier
Accepted (2)
87533 HHV-6 DNA QUANT
01/01/2016 Yes
87534 HIV-1 DNA DIR PROBE
01/01/2016 Yes
87535 HIV-1 PROBE&REVERSE TRNSCRPJ
01/01/2016 Yes
87536 HIV-1 QUANT&REVRSE TRNSCRPJ
01/01/2016 Yes
87537 HIV-2 DNA DIR PROBE
01/01/2016 Yes
87538 HIV-2 PROBE&REVRSE TRNSCRIPJ
01/01/2016 Yes
87539 HIV-2 QUANT&REVRSE TRNSCRIPJ
01/01/2016 Yes
87540 LEGION PNEUMO DNA DIR PROB
01/01/2016 Yes
87541 LEGION PNEUMO DNA AMP PROB
01/01/2016 Yes
87542 LEGION PNEUMO DNA QUANT
01/01/2016 Yes
87550 MYCOBACTERIA DNA DIR PROBE
01/01/2016 Yes
87551 MYCOBACTERIA DNA AMP PROBE
01/01/2016 Yes
87552 MYCOBACTERIA DNA QUANT
01/01/2016 Yes
87555 M.TUBERCULO DNA DIR PROBE
01/01/2016 Yes
87556 M.TUBERCULO DNA AMP PROBE
01/01/2016 Yes
87557 M.TUBERCULO DNA QUANT
01/01/2016 Yes
87560 M.AVIUM-INTRA DNA DIR PROB
01/01/2016 Yes
87561 M.AVIUM-INTRA DNA AMP PROB
01/01/2016 Yes
87562 M.AVIUM-INTRA DNA QUANT
01/01/2016 Yes
87580 M.PNEUMON DNA DIR PROBE
01/01/2016 Yes
87581 M.PNEUMON DNA AMP PROBE
01/01/2016 Yes
87582 M.PNEUMON DNA QUANT
01/01/2016 Yes
87590 N.GONORRHOEAE DNA DIR PROB
01/01/2016 Yes
87591 N.GONORRHOEAE DNA AMP PROB
01/01/2016 Yes
87592 N.GONORRHOEAE DNA QUANT
01/01/2016 Yes
87623 HPV LOW-RISK TYPES
01/01/2016 Yes
87624 HPV HIGH-RISK TYPES
01/01/2016 Yes
87625 HPV TYPES 16 & 18 ONLY
01/01/2016 Yes
87631 RESP VIRUS 3-5 TARGETS
01/01/2016 Yes
87632 RESP VIRUS 6-11 TARGETS
01/01/2016 Yes
87633 RESP VIRUS 12-25 TARGETS
01/01/2016 Yes
87640 STAPH A DNA AMP PROBE
01/01/2016 Yes
87641 MR-STAPH DNA AMP PROBE
01/01/2016 Yes
87650 STREP A DNA DIR PROBE
01/01/2016 Yes
87651 STREP A DNA AMP PROBE
01/01/2016 Yes
87652 STREP A DNA QUANT
01/01/2016 Yes
87653 STREP B DNA AMP PROBE
01/01/2016 Yes
87660 TRICHOMONAS VAGIN DIR PROBE
01/01/2016 Yes
87661 TRICHOMONAS VAGINALIS AMPLIF
01/01/2016 Yes
87797 DETECT AGENT NOS DNA DIR
01/01/2016 Yes
87798 DETECT AGENT NOS DNA AMP
01/01/2016 Yes
87799 DETECT AGENT NOS DNA QUANT
01/01/2016 Yes
87800 DETECT AGNT MULT DNA DIREC
01/01/2016 Yes
87801 DETECT AGNT MULT DNA AMPLI
01/01/2016 Yes
88271 CYTOGENETICS DNA PROBE
01/01/2016 Yes
88272 CYTOGENETICS 3-5
01/01/2016 Yes
88273 CYTOGENETICS 10-30
01/01/2016 Yes
88274 CYTOGENETICS 25-99
01/01/2016 Yes
88275 CYTOGENETICS 100-300
01/01/2016 Yes
88291 CYTO/MOLECULAR REPORT
01/01/2016 Yes
88364 INSITU HYBRIDIZATION (FISH)
01/01/2016 Yes
88365 INSITU HYBRIDIZATION (FISH)
01/01/2016 Yes
88366 INSITU HYBRIDIZATION (FISH)
01/01/2016 Yes
88367 INSITU HYBRIDIZATION AUTO
01/01/2016 Yes
88368 INSITU HYBRIDIZATION MANUAL
01/01/2016 Yes
88369 M/PHMTRC ALYSISHQUANT/SEMIQ
01/01/2016 Yes
88373 M/PHMTRC ALYS ISHQUANT/SEMIQ
01/01/2016 Yes
88374 M/PHMTRC ALYS ISHQUANT/SEMIQ
01/01/2016 Yes
88377 M/PHMTRC ALYS ISHQUANT/SEMIQ
01/01/2016 Yes
G0452 Molecular pathology interpr
01/01/2018 Yes
G0476 Hpv combo assay ca screen
07/01/2016 Yes
(1) These codes will be denied when submitted for payment on the same date of service as 81162.

(2) "Yes" indicates that the use of a modifier with the denied code will overcome the edit and allow payment.
"No" indicates that the second code will always be denied.



Column 2 CCI Edits for 81162

Denied Codes (1)
Effective
Modifier
Accepted (2)
0001U RBC DNA HEA 35 AG 11 BLD GRP
01/01/2018 Yes
0005U ONCO PRST8 3 GENE UR ALG
01/01/2018 Yes
0008U HPYLORI DETCJ ABX RSTNC DNA
01/01/2018 Yes
0010U NFCT DS STRN TYP WHL GEN SEQ
01/01/2018 Yes
0012U GERMLN DO GENE REARGMT DETCJ
01/01/2018 Yes
0013U ONC SLD ORG NEO GENE REARGMT
01/01/2018 Yes
0014U HEM HMTLMF NEO GENE REARGMT
01/01/2018 Yes
0018U ONC THYR 10 MICRORNA SEQ ALG
07/01/2018 Yes
0019U ONC RNA TISS PREDICT ALG
07/01/2018 Yes
0022U TRGT GEN SEQ DNA&RNA 23 GENE
07/01/2018 Yes
0023U ONC AML DNA DETCJ/NONDETCJ
07/01/2018 Yes
0026U ONC THYR DNA&MRNA 112 GENES
07/01/2018 Yes
0036U XOME TUM & NML SPEC SEQ ALYS
01/01/2019 Yes
0037U TRGT GEN SEQ DNA 324 GENES
01/01/2019 Yes
0045U ONC BRST DUX CARC IS 12 GENE
01/01/2019 Yes
0047U ONC PRST8 MRNA 17 GENE ALG
01/01/2019 Yes
0048U ONC SLD ORG NEO DNA 468 GENE
01/01/2019 Yes
0050U TRGT GEN SEQ DNA 194 GENES
01/01/2019 Yes
0055U CARD HRT TRNSPL 96 DNA SEQ
01/01/2019 Yes
0056U HEM AML DNA GENE REARGMT
01/01/2019 Yes
0057U ONC SLD ORG NEO MRNA 51 GENE
01/01/2019 Yes
0060U TWN ZYG GEN SEQ ALYS CHRMS2
01/01/2019 Yes
81228 CYTOGEN MICRARRAY COPY NMBR
01/01/2016 Yes
81229 CYTOGEN M ARRAY COPY NO&SNP
01/01/2016 Yes
81410 AORTIC DYSFUNCTION/DILATION
01/01/2016 Yes
81411 AORTIC DYSFUNCTION/DILATION
01/01/2016 Yes
81412 ASHKENAZI JEWISH ASSOC DIS
01/01/2016 Yes
81413 CAR ION CHNNLPATH INC 10 GNS
01/01/2017 Yes
81414 CAR ION CHNNLPATH INC 2 GNS
01/01/2017 Yes
81415 EXOME SEQUENCE ANALYSIS
01/01/2016 Yes
81416 EXOME SEQUENCE ANALYSIS
01/01/2016 Yes
81417 EXOME RE-EVALUATION
01/01/2016 Yes
81420 FETAL CHRMOML ANEUPLOIDY
01/01/2016 Yes
81422 FETAL CHRMOML MICRODELTJ
01/01/2017 Yes
81425 GENOME SEQUENCE ANALYSIS
01/01/2016 Yes
81426 GENOME SEQUENCE ANALYSIS
01/01/2016 Yes
 
Denied Codes (1)
Effective
Modifier
Accepted (2)
81427 GENOME RE-EVALUATION
01/01/2016 Yes
81430 HEARING LOSS SEQUENCE ANALYS
01/01/2016 Yes
81431 HEARING LOSS DUP/DEL ANALYS
01/01/2016 Yes
81432 HRDTRY BRST CA-RLATD DSORDRS
01/01/2016 No
81433 HRDTRY BRST CA-RLATD DSORDRS
01/01/2016 No
81434 HEREDITARY RETINAL DISORDERS
01/01/2016 Yes
81435 HEREDITARY COLON CA DSORDRS
01/01/2016 Yes
81436 HEREDITARY COLON CA DSORDRS
01/01/2016 Yes
81437 HEREDTRY NURONDCRN TUM DSRDR
01/01/2016 Yes
81438 HEREDTRY NURONDCRN TUM DSRDR
01/01/2016 Yes
81439 HRDTRY CARDMYPY GENE PANEL
01/01/2017 Yes
81440 MITOCHONDRIAL GENE
01/01/2016 Yes
81442 NOONAN SPECTRUM DISORDERS
01/01/2016 Yes
81443 GENETIC TSTG SEVERE INH COND
01/01/2019 Yes
81445 TARGETED GENOMIC SEQ ANALYS
01/01/2016 Yes
81448 HRDTRY PERPH NEURPHY PANEL
01/01/2018 Yes
81450 TARGETED GENOMIC SEQ ANALYS
01/01/2016 Yes
81455 TARGETED GENOMIC SEQ ANALYS
01/01/2016 Yes
81460 WHOLE MITOCHONDRIAL GENOME
01/01/2016 Yes
81465 WHOLE MITOCHONDRIAL GENOME
01/01/2016 Yes
81470 X-LINKED INTELLECTUAL DBLT
01/01/2016 Yes
81471 X-LINKED INTELLECTUAL DBLT
01/01/2016 Yes
81493 COR ARTERY DISEASE MRNA
01/01/2016 Yes
81504 ONCOLOGY TISSUE OF ORIGIN
01/01/2016 Yes
81507 FETAL ANEUPLOIDY TRISOM RISK
01/01/2016 Yes
81518 ONC BRST MRNA 11 GENES
01/01/2019 Yes
81519 ONCOLOGY BREAST MRNA
01/01/2016 Yes
81520 ONC BREAST MRNA 58 GENES
01/01/2018 Yes
81521 ONC BREAST MRNA 70 GENES
01/01/2018 Yes
81525 ONCOLOGY COLON MRNA
01/01/2016 Yes
81528 ONCOLOGY COLORECTAL SCR
01/01/2016 Yes
81540 ONCOLOGY TUM UNKNOWN ORIGIN
01/01/2016 Yes
81541 ONC PROSTATE MRNA 46 GENES
01/01/2018 Yes
81545 ONCOLOGY THYROID
01/01/2016 Yes
81551 ONC PROSTATE 3 GENES
01/01/2018 Yes
81595 CARDIOLOGY HRT TRNSPL MRNA
01/01/2016 Yes
(1) These codes will be denied when submitted for payment on the same date of service as 81162.

(2) "Yes" indicates that the use of a modifier with the denied code will overcome the edit and allow payment.
"No" indicates that the second code will always be denied.


Medically Unlikely Edits for 81162


Practitioner
Hospital Outpatient
DME Supplier
Allowed Frequency per Day: 1 1 Not Listed
Adjudication Indicator: 2 Date of Service Edit: Policy 2 Date of Service Edit: Policy Not Listed
Rationale: Nature of Analyte Nature of Analyte Not Listed

* CCI Source Data: Practitioner P2P Coding Edits. For more information on these edits or to view the Hospital Outpatient Edits, please visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

MUE Source Data: For more information on these edits, please visit href='https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

The responsibility for the content of any "National Correct Coding Policy" included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse, or interpretation of information contained in this product.



   81162 Top 5 Ordering Organizations National*
MYRIAD GENETIC LABORATORIES, INC.-UT 8,637
AMBRY GENETICS CORPORATION-CA 7,335
LABORATORY CORPORATION OF AMERICA HOLDINGS-NC 222
GENEDX, INC.-MD 95
UNILAB CORPORATION-CA 34

*Based on 2016 Medicare Fee-For Service Provider Utilization & Payment Data, Physician and Other Supplier, Public Use File



   Medicare Part B Utilization Data for 81162*         Hide this section.



Annual Performed / Denied


Total National Services (all modifiers) Submitted 2017: 30,208
Total Services Denied 2017: 9,190 (30.4%)
National Charges Submitted 2017: $119,147,585.57
National Charges Allowed 2017: $ 52,484,617.84
National Average (No Modifier) Fee Submitted 2017: $3953.81
National Average (No Modifier) Fee Allowed 2017: $2496.99


Top 5 Performing Specialties 2017 Total Services Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
Clinical laboratory
(billing independently)
30,208 100.0% $3944.24 9,190 30.4%

Top 5 Places of Service 2017 Total Services Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
Independent laboratory 30,201 100.0% $3944.39 9,185 30.4%
Office 5 0.0% $3438.40 4 80.0%
On Campus-Outpatient Hospital 2 0.0% $2890.00 1 50.0%

Top 5 Modifiers Submitted 2017 Total Services Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
No Modifier 27,721 91.8% $3953.81 7,189 25.9%
GA - Advanced Beneficiary Notice (ABN) on File 2,063 6.8% $3987.06 1,740 84.3%
90 - Reference (Outside) Laboratory 349 1.2% $2988.75 196 56.2%
GZ - Service Expected to be Denied as Not Reasonable and Necessary 39 0.1% $3381.09 38 97.4%
91 - Repeat Clinical Diagnostic Laboratory Test 31 0.1% $4034.84 23 74.2%

Click here for more information on Custom CodeMap Medicare Utililation Reports.


*Utilization data is derived from analysis of the Physician Supplier Procedure Summary Master File (PSPSMF) which includes data from all Medicare Part B carriers. This data represents procedure-specific billing data for all physician/supplier services rendered to all Medicare beneficiaries during the calendar year named and processed by the Carriers through the six months of the following year.

Part B charge and utilization data for institutional services (hospital outpatient departments, home health agencies, comprehensive outpatient rehabilitation facilities, end-stage renal disease facilities, and rural health clinics) are processed by Medicare Part A fiscal intermediaries and are not included in this data. Data for services rendered to beneficiaries enrolled in risk-based Health Maintenance Organizations (HMOs) are also not included.


   CodeMap Compliance Briefings: Hide this section.

CMS Transmittals Referencing "81162"
Issue DateTransmittalTitle
2018-12-21 R4185CP January 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.0
2018-03-16 R4000CP Internet Only Manual Update to Pub 100-04, Chapter 16, Section 40.8 - Date of Service Policy
2017-05-12 R1846OTN MCS Implementation of the Restructured Clinical Lab Fee Schedule


All information on this web site is compiled directly from information obtained from the Center for Medicare and Medicaid Services (CMS) and from its Contractors.

CodeMap® has made every reasonable effort to ensure the accuracy of the information contained on this web site. However, the ultimate responsibility for correct coding and claims submission lies with the provider of services. CodeMap® makes no representation, warranty, or guarantee that this compilation of Medicare information is error-free or that the use of this information will result in Medicare coverage and subsequent payment of claims. Final coverage and payment of claims are subject to many factors exclusively controlled by CMS and its contractors.

No part of this web page or data displayed may be redistibuted or used without the express written consent of Wheaton Partners, LLC.
01/23/2019 08:21:04 54.172.221.7

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