ACPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
Genotyping for CYP2C19:
CPT codes covered if selection criteria are met:
81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17)
CPT codes not covered for indications listed in the CPB:
81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6)
ICD-hyphen10 codes covered if selection criteria are met:
I25.10 -hyphen I25.9 Chronic ischemic heart disease
Genotyping for CYP2D6:
CPT codes covered if selection criteria are met:
0028U CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, copy number variants, common variants with reflex to targeted sequence analysis
81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)
Other HCPCS codes related to the CPB:
J1800 Injection, propranolol HCl, up to 1 mg
ICD-hyphen10 codes covered if selection criteria are met:
E75.22 Gaucher disease [for persons with Gaucher's disease type 1 who are being considered for treatment with eligustat (Cerdelga)]
G10 Huntington's disease [Tetrabenazine (Xenazine) is indicated for the treatment of chorea associated with Huntington’s disease]
Genotyping for cytochrome P450:
No specific code
CPT code not covered for indications listed in the CPB:
0029U Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823)
0030U Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823)
0031U CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7)
81230 CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22)
81231 CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7)
81232 DPYD (dihydropyrimidine dehydrogenase) (eg, 5-hyphenfluorouracil/5-hyphenFU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6)
81346 TYMS (thymidylate synthetase) (eg, 5-hyphenfluorouracil/5-hyphenFU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant)
CPT codes related to the CPB:
81400 -hyphen 81408 Molecular pathology
HCPCS codes not covered for indications listed in the CPB:
G9143 Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)
Other HCPCS codes related to the CPB:
J0640 Injection, leucovorin calcium, per 50 mg
J1630 Injection, haloperidol, up to 5 mg
J1631 Injection, haloperidol decanoate, per 50 mg
J2270 Injection, morphine sulfate, up to 10 mg
J2271 Injection, morphine sulfate, 100 mg
J2275 Injection, morphine sulfate (preservative-hyphenfree sterile solution), per 10 mg
J2794 Injection, risperidone, long acting, 0.5 mg
J3310 Injection, perphenazine, up to 5 mg
J3360 Injection, diazepam, up to 5 mg
J8530 Cyclophosphamide, oral, 25 mg
J9070 Cyclophosphamide, 100 mg
J9190 Fluorouracil, 500 mg
J9206 Irinotecan, 20 mg
J9263 Injection, oxaliplatin, 0.5 mg
Q0175 Perphenazine, 4 mg, oral, FDA approved prescription anti-hyphenemetic, for use as a complete therapeutic substitute for an IV anti-hyphenemetic at the time of chemotherapy treatment, not to exceed a 48-hyphenhour dosage regimen
S0093 Injection, morphine sulfate, 500 mg (loading doe for infusion pump)
S0187 Tamoxifen citrate, oral, 10 mg
ICD-hyphen10 codes not covered for indications listed in the CPB:
G30. 0 -hyphen G30.9 Alzheimer's disease
CYP2C19 polymorphisms testing for fluoxetine:
CPT codes not covered for indications listed in the CPB:
81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17)
UGT1A1 molecular assay:
CPT codes not covered for indications listed in the CPB:
81350 UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, irinotecan metabolism), gene analysis, common variants (eg, *28, *36, *37)
Other HCPCS codes related to the CPB:
J9206 Irinotecan, 20 mg
ICD-hyphen10 codes not covered for indications listed in the CPB:
C00.0 -hyphen C7A.8, C7B.1, C76.0 -hyphen C86.6,
C88.4 -hyphen C94.32, C94.80 -hyphen C96.4,
C96.6 -hyphen C96.9
Malignant neoplasms
D00.00 -hyphen D09.9 In situ neoplasms
D45 Polycythemia vera
VKORC1 polymorphism:
CPT codes not covered for indications listed in the CPB:
81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -hyphen1639G>A, c.173+1000C>T)
HLA-hyphenB*1502:
No specific codes
HLA-hyphenB*5701:
No specific code
ICD-hyphen10 codes covered if selection criteria are met:
B20 Human immunodeficiency virus [HIV] disease
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Genotyping for apolipoprotein E (Apo E):
No specific code
Other CPT codes related to the CPB :
88271 -hyphen 88275 Molecular cytogenetics
ICD-hyphen10 codes not covered for indications listed in the CPB (not all-hypheninclusive):
E71.30 Disorder of fatty-hyphenacid metabolism, unspecified
E75.5 -hyphen E75.6 Other and unspecified lipid storage disorders
E78.0 -hyphen E78.5, E78.70, E78.79 -hyphen E78.9
Disorders of lipoprotein metabolism and other lipidemias
E88.2 Lipomatosis, not elsewhere classified
E88.89 Other specified metabolic disorders
Genotyping for methylenetetrahydrofolate reductase (MTHFR):
CPT codes not covered for indictions listed in the CPB :
81291 MTHFR (5,10-hyphenmethylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C)
ICD-hyphen10 codes not covered for indications listed in the CPB (not all-hypheninclusive):
C00.0 -hyphen C7A.8, C7B.1, C76.0 -hyphen C86.6,
C88.4 -hyphen C94.32, C94.80 -hyphen C96.4,
C96.6 -hyphen C96.9
Malignant neoplasms
D00.00 -hyphen D09.9 In situ neoplasms
D45 Polycythemia vera
Measurement of thromboxane metabolites in urine:
CPT codes not covered for indications listed in the CPB:
84431 Thromboxane metabolite(s), including thromboxane if performed, urine
BRAF V600E or V600K mutations (e.g., the THxID BRAF test):
CPT codes covered if selection criteria are met:
81210 BRAF (B-hyphenRaf proto-hyphenoncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s)
ICD-hyphen10 codes covered by indications listed in the CPB:
C43.0 -hyphen C43.9 Malignant melanoma of skin
NS3 Q80K polymorphism, NS5A resistance-hyphenassociated polymorphisms:
CPT codes covered if selection criteria are met:
87900 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics [for persons with hepatitis C virus (HCV) genotype 1a infection being considered for treatment with simeprevir (Olysio)] [for persons with hepatitis C virus (HCV) genotype 1, 3 and 4 infections being considered for treatment with daclatasvir (Daklinza) or elbasvir and grazoprevir (Zepatier)]
87902 Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus [for persons with hepatitis C virus (HCV) genotype 1a infection being considered for treatment with simeprevir (Olysio)] [for persons with hepatitis C virus (HCV) genotype 1, 3 and 4 infections being considered for treatment with daclatasvir (Daklinza) or elbasvir and grazoprevir (Zepatier)]
ICD-hyphen10 codes covered if selection criteria are met:
B17.10 -hyphenB17.11 Acute hepatitis C without/with hepatic coma [genotype 1, 1a, 3, 4 infections]
B18.2 Chronic viral hepatitis C [genotype 1, 1a, 3, 4 infections]
B19.20 -hyphen B19.21 Unspecified viral hepatitis C [genotype 1, 1a, 3, 4 infections]
Z22.52 Carrier of viral hepatitis C [genotype 1, 1a, 3, 4 infections]
BRACAnalysis CDx, FoundationFocus CDxBRCA:
CPT codes covered if selection criteria are met:
81162 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis
81211 BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-hyphen20 del 26kb, exon 22 del 510bp, exon 8-hyphen9 del 7.1kb)
ICD-hyphen10 codes covered if selection criteria are met:
C50.011 -hyphen C50.929 Malignant neoplasm of breast [HER2-hyphennegative]
C56.1 -hyphen C56.9 Malignant neoplasm of ovary
BRAF and NRAS mutations (e.g., cobas KRAS Mutation Test; therascreen KRAS RGQ PCR Kit):
CPT codes covered if selection criteria are met:
81210 BRAF (B-hyphenRaf proto-hyphenoncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s)
81311 NRAS (neuroblastoma RAS viral [v-hyphenras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61)
Other HCPCS codes related to the CPB:
J9055 Injection, cetuximab, 10 mg
J9303 Injection, panitumumab, 10 mg
ICD-hyphen10 codes covered if selection criteria are met:
C18.0 -hyphen C20 Malignant neoplasm of colon, rectosigmoid junction and rectum
Epidermal growth factor receptor (EGFR) T790 mutation; exon 19 deletions or exon 21 (L858R) substitution mutations (e.g., cobas EGFR Mutation Test, therascreen EGFR RGQ PCR Kit):
CPT codes covered if selection criteria are met:
81235 EGFR ( epidermal growth factor receptor) (eg, non-hyphensmall cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q)
ICD-hyphen10 codes covered if selection criteria are met:
C34.00 -hyphen C34.92 Malignant neoplasm of bronchus and lung [non-hyphensmall cell lung carcinoma]
PD-hyphenL1 expression (e.g., PD-hyphenL1 IHC 22C3 pharmDx, Ventana PD-hyphenL1 (SP263) Assay):
CPT codes covered if selection criteria are met:
88360 Morphometric analysis, tumor immunohistochemistry (eg, Her-hyphen2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual
88361 using computer-hyphenassisted technology
Other HCPCS codes related to the CPB:
J9271 Injection, pembrolizumab, 1 mg
ICD-hyphen10 codes covered if selection criteria are met:
C65.1 -hyphen C65.9 Malignant neoplasm of renal pelvis [urothelial carcinoma]
C66.1 -hyphen C66.9 Malignant neoplasm of ureter [urothelial carcinoma]
C67.0 -hyphen C67.9 Malignant neoplasm of bladder, unspecified [urothelial carcinoma]
C68.0 -hyphen C68.9 Malignant neoplasm of other and unspecified urinary organs [urothelial carcinoma]
Platelet-hyphenderived growth factor receptor-hyphenbeta (PDGFRß) gene rearrangements (e.g., PDGFRB FISH):
CPT codes covered if selection criteria are met:
88271 Molecular cytogenetics; DNA probe, each (eg, FISH)
88275 interphase in situ hybridization, analyze 100-hyphen300 cells
ICD-hyphen10 codes covered if selection criteria are met:
C93.10 -hyphen C93.12 Chronic myelomonocytic leukemia
FTL3 mutation assay (e.g., LeukoStrat CDx FLT Mutation Assay):
CPT codes covered if selection criteria are met:
0023U Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-hyphendetection of FLT3 mutation and indication for or against the use of midostaurin
81245 FLT3 (fms-hyphenrelated tyrosine kinase 3) (eg, acute nyeloid leukemia), gene analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15)
81246 tyrosine kinase domain (TKD) variants (eg D835, I836)
ICD-hyphen10 codes covered if selection criteria are met:
C92.00 -hyphen C92.02 Myeloid leukemia
Measurement of microsatellite instability and mismatch repair:
CPT codes covered if selection criteria are met:
81301 Microsatellite instability analysis (eg, hereditary non-hyphenpolyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed
88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure)
88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure [mismatch repair]
Other HCPCS codes related to the CPB:
J9271 Injection, pembrolizumab, 1 mg
ICD-hyphen10 codes covered if selection criteria are met:
C00.0 -hyphen C14.8 Malignant neoplasm of lip, oral cavity and pharynx
C15.3 -hyphen C26.9 Malignant neoplasm of digestive organs
C30.0 -hyphen C39.9 Malignant neoplasm of respiratory and intrathoracic organs
C40.00 -hyphen C41.9 Malignant neoplasm of bone and articular cartilage
C49.0 -hyphen C49.9 Malignant neoplasm of other connective and soft tissue
C7A.00 -hyphen C7A.8 Malignant neuroendocrine tumors
Extended RAS Panel -hyphen no specific code:
Anaplastic lymphoma kinase (ALK) fusion gene testing, (Vysis ALK Break Apart FISH Probe Kit; Ventana ALK (D5F3) CDx Assay):
No specific code
ICD-hyphen10 codes covered if selection criteria are met:
C34.00 -hyphen C34.92 Malignant neoplasm of bronchus and lung [non-hyphensmall cell lung carcinoma]
Genotyping for IL28B polymorphism:
ICD-hyphen10 codes not covered for indications listed in the CPB:
B19.20 Unspecified viral hepatitis C without hepatic coma
rs3798220 allele testing:
No specific code
ICD-hyphen10 codes not covered for indications listed in the CPB:
Z79.82 Long-hyphenterm (current) use of aspirin
G551D, G1244E, G1349D, G178R, G551S, R117H, S1251N, S1255P, S549N, and S549R mutation in the CFTR testing:
No specific code
ICD-hyphen10 covered for indications listed in the CPB:
E84.0 -hyphen E84.9 Cystic fibrosis [who are being considered for treatment with ivacaftor (Kalydeco)]
F508del mutation in the CFTR testing:
CPT codes covered if selection criteria are met:
81222 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants
ICD-hyphen10 codes covered for indications listed in the CPB:
E84.0-hyphenE84.9 Cystic fibrosis [who are being considered for treatment with lumacaftor/ivacaftor (Orkambi)]
GeneSightRx testing (GeneSight ADHD, GeneSight Analgesic, GeneSight MTHFR and GeneSight Psychotropic):
No specific code
ICD-hyphen10 codes not covered for indications listed in the CPB:
F30.10 -hyphen F39 Mood [affective] disorders
Platelet reactivity/function testing (VerifyNow P2Y12 Assay):
No specific code
ICD-hyphen10 codes not covered for indications listed in the CPB:
Z98.61 Coronary angioplasty status
OnDose lab test:
HCPCS codes not covered for indications listed in the CPB:
S3722 Dose optimization by area under the curve (AUC) analysis, for infusional 5-hyphenFluorouracil
MGMT (O(6)-hyphenmethylguanine-hyphenDNA methyltransferase) gene methylation Assay:
CPT codes covered if selection criteria are met:
81287 MGMT (O-hyphen6-hyphenmethylguanine-hyphenDNA methyltransferase) (eg, glioblastoma multiforme), methylation analysis
Other HCPCS codes related to the CPB:
J8700 Temozolomide, oral, 5 mg
J9328 Injection, temozolomide, 1 mg
ICD-hyphen10 covered for indications listed in the CPB:
C71.0 -hyphen C71.9 Malignant neoplasm of brain [glioblastoma]
Genecept Assay:
No specific code
ICD-hyphen10 codes not covered for indications listed in the CPB (not all inclusive):
F20.0 -hyphen F20.9 Schizophrenia
F30.10 -hyphen F39 Mood [affective] disorders
F32.0 -hyphen F32.9 Major depressive disorders
F34.0 -hyphen F34.9 Persistent mood [affective] disorders
F40.00 -hyphen F48.9 Anxiety, dissociative, stress-hyphenrelated, somatoform and other nonpsychotic mental disorders
F90.1 -hyphen F90.9 Attention-hyphendeficit hyperactivity disorder
Beta adrenergic receptor genotyping:
CPT codes not covered for indications listed in the CPB:
81401 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -hyphen1639G>A, c.173+1000C>T)
ICD-hyphen10 codes not covered for indications listed in the CPB:
J45.20 -hyphen J45.998 Asthma [treatment resistant]
Methotrexate polyglutamates (Avise PG test):
No specific code
Other HCPCS codes related to the CPB:
J8610 Methotrexate; oral, 2.5 mg
J9250 Methotrexate sodium, 5 mg
J9260 Methotrexate sodium, 50 mg
ICD-hyphen10 codes not covered for indications listed in the CPB (not all inclusive):
M05.00 -hyphen M14.89 Inflammatory polyarthropathies
Millennium PGT:
No specific code
ICD-hyphen10 codes not covered for indications listed in the CPB (not all inclusive):
G89.21 -hyphen G89.29 Chronic pain, not elsewhere classified
PersonaGene Genetic Panels:
CPT codes not covered for indications listed in the CPB:
81225 CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17)
81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)
81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6)
81240 F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant
81241 F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant
81291 MTHFR (5,10-hyphenmethylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C)
81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -hyphen1639G>A, c.173+1000C>T)
81401 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg, warfarin metabolism), gene analysis, common variant(s) (eg, -hyphen1639G>A, c.173+1000C>T)
ICD-hyphen10 codes not covered for indications listed in the CPB (not all inclusive):
Z51.81 Encounter for therapeutic drug level monitoring
HLA-hyphenB 58:01:
CPT codes covered if selection criteria are met:
No specific code
Aegis Drug-hyphenDrug Interaction Test:
CPT codes not covered for indications listed in the CPB:
0006U Prescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service
OneOme RightMed Pharmacogenomic Test:
CPT codes not covered for indications listed in the CPB:
0015U Drug metabolism (adverse drug reactions), DNA, 22 drug metabolism and transporter genes, real-hyphentime PCR, blood or buccal swab, genotype and metabolizer status for therapeutic decision support
Genotyping of interferon-hyphenlambda 3 (IFNL3) for prediction of virological response to pegylated-hypheninterferon-hyphenalpha and ribavirin combination therapy:
CPT codes not covered for indications listed in the CPB:
81283 IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant
PGxOnePlus genetic testing -hyphen no specific code:
ICD-hyphen10 codes not covered for indications listed in the CPB (not all inclusive):
F40.00 -hyphen F48.9 Anxiety, dissociative, stress-hyphenrelated, somatoform and other nonpsychotic mental disorders
K21.0, K21.9
Gastro-hyphenesophageal reflux disease with or without esophagitis
UrSure tenofovir quantification test:
CPT codes not covered for indications listed in the CPB:
0025U Tenofovir, by liquid chromatography with tandem mass spectrometry (LC-hyphenMS/MS), urine, quantitative
ICD-hyphen10 codes not covered for indications listed in the CPB (not all inclusive):
Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z20.828 Contact with and (suspected) exposure to other viral communicable diseases
Experimental and Investigation Treatment -hyphen no specific codes:
A1555G, Amerigene PGT pharmacogenetic testing panel, Proove Profiles (including Proove Opioid Risk Panel, Proove Opioid Response Profile, Proove Non-hyphenopioid Response Profile, Proove Opioid-hyphenInduced Side Effects Profile, Proove NSAID Risk Profile, Proove Fibromyalgia Profile, Proove Epidural with Fentanyl Response Profile, Proove MAT (Medically Assisted Treatment) Response Profile, Proove TMD Profile, Proove Psychiatric Risk and Response Profile, Proove Addiction Profile, Proove Narcotic Risk Panel, Proove Drug Metabolism Panel, rxSEEK Epilepsy Drug Metabolism Test (Courtagen LIfe Sciences