This reimbursement policy defines operational requirements for billing Molecular Diagnostic Tests (MDTs) and molecular pathology services to UnitedHealthcare Community Plan Medicaid. Providers must submit the correct Molecular Pathology CPT/HCPCS code that most accurately describes the test performed and must include the associated Palmetto DEX Z-Code® identifier (a 5-character proprietary code) adjacent to the CPT/HCPCS code on the claim so the service can be considered for reimbursement. The DEX Z-Code® should be reported in the claim comment/narrative field: Loop 2400 / SV-101-7 (837P) or Box 19 (paper) for professional claims, and Line SV-202-7 (837I) or Block 80 (UB04) for facility claims. Providers are required to report 1 unit of service (UOS) for each single-specimen MDT claim. (See resources for DEX registry access and registration instructions.)
For tests that involve multiple genes but yield a single result, submit a single CPT code and one DEX Z-Code®; UnitedHealthcare will deny duplicate or multiple molecular CPT codes reported with the same DEX Z-Code® for the same patient on the same date of service. In the rare circumstance where separate specimens are tested on the same date for distinctly separate indications, an additional code may be reported for the additional specimen with an appropriate modifier supported by the test requisition and documentation, consistent with CMS national correct coding policy.
Laboratories must register in the Palmetto DEX® Diagnostic Exchange to obtain Z-Codes and to link performing and billing providers when tests are referred to a reference laboratory. If using a reference lab, request 'sharing' in DEX® so the billing provider can use the performing provider's Z-Code. The most current list of CPT codes subject to the DEX registry and instructions for registration are available on the Palmetto DEX® website.
This policy applies to services billed on CMS-1500, UB-04 or electronic equivalents for UnitedHealthcare Community Plan Medicaid and applies to all products and providers except for the following state exceptions: Arizona, Colorado, District of Columbia, Indiana, Kansas, Kentucky, Louisiana, Maryland, Mississippi, Missouri, Nebraska, New Jersey, North Carolina, and Ohio. Tennessee has a state-specific provision: Tennessee will cover procedure codes listed in the attachment as Rapid Genetic testing for newborns less than 1 year old. For additional operational questions about registration, sharing, and test mapping for custom panels, see the Palmetto DEX® registry guidance on the DEX website.