81286 A TAR for CPT code requires documentation of Yes the following criteria: FXN (frataxin) gene analysis; any full gene sequence The patient has clinical signs or symptoms provider, suspicious for Friedreich ataxia (FRDA), and except with The patient requires the service as a confirmatory valid TAR test for FRDA override 81287 While DHCS requires a TAR for this test, PHC has No Indicated for: chosen to have no TAR requirement when billed MGMT (0-6 The patient has the diagnosis of glioblastoma with ICD-10 code C71.9 methyltransferase) any multiforme, and methylation analysis provider, Treatment strategy will be contingent on the except with test results valid TAR Reimbursable when billed with ICD-10 : C71.9. override 81288 Yes Document the following criteria on the TAR: MLH1 gene analysis; Patient with cancer, and any promoter methylation The tumor demonstrates microsatellite provider, analysis instability or immunohistochemistry results except with indicating loss of MLH1 protein expression TAR override Yes 81289 A TAR for CPT code 81289 requires documentation of the following criteria: FXN (frataxin) gene analysis; any known familial variant(s) The patient has clinical signs or symptoms provider, suspicious for Friedreich ataxia (FRDA), and except with The patient requires the service as a confirmatory valid TAR test for FRDA override 81292 No One of the following ICD-10-CM codes is required on the claim: MLH1 (mutL homolog 1, any colon cancer, nonpolyposis C17.0 C20, C24.0 C25.9, C54.0 C54.9, C65.1 – – – – provider, type 2) gene analysis; full C66.9, C71.0 C71.9, D23.0 D23.9, Z80.0, Z80.49, – – except with sequence analysis Z85.030, Z85.038, Z85.040, Z85.048, Z85.42 valid TAR override
81286 FXN (frataxin) gene analysis; full gene sequence Yes A TAR for CPT code requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Friedreich ataxia (FRDA), and The patient requires the service as a confirmatory test for FRDA any provider, except with valid TAR override 81287 MGMT (0-6 methyltransferase) methylation analysis No Indicated for: The patient has the diagnosis of glioblastoma multiforme, and Treatment strategy will be contingent on the test results Reimbursable when billed with ICD-10 : C71.9. any provider, except with valid TAR override While DHCS requires a TAR for this test, PHC has chosen to have no TAR requirement when billed with ICD-10 code C71.9 81288 MLH1 gene analysis; promoter methylation analysis Yes Document the following criteria on the TAR: Patient with cancer, and The tumor demonstrates microsatellite instability or immunohistochemistry results indicating loss of MLH1 protein expression any provider, except with TAR override 81289 FXN (frataxin) gene analysis; known familial variant(s) Yes A TAR for CPT code 81289 requires documentation of the following criteria: The patient has clinical signs or symptoms suspicious for Friedreich ataxia (FRDA), and The patient requires the service as a confirmatory test for FRDA any provider, except with valid TAR override 81292 MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) gene analysis; full sequence analysis No One of the following ICD-10-CM codes is required on the claim: C17.0 – C20, C24.0 – C25.9, C54.0 – C54.9, C65.1 – C66.9, C71.0 – C71.9, D23.0 – D23.9, Z80.0, Z80.49, Z85.030, Z85.038, Z85.040, Z85.048, Z85.42 any provider, except with valid TAR override