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| STATES / TERRITORIES | PHONE · PORTAL | CLAIM VOLUME | BENEFICIARIES |
|---|---|---|---|
| 1-855-252-8782 · Novitasphere JL | ~200 million claims/year | ~3.4 million Medicare FFS |
J15 is a MolDX jurisdiction. Any lab billing molecular diagnostic tests, CPT codes in the 81XXX range, or most PLA codes needs an active DEX Z-Code from Palmetto GBA’s DEX platform (dexzcodes.com) registered before those claims go out the door.
Claims without a valid Z-Code are denied automatically, with no manual override at the claims level. Confirming your DEX Z-Code registration is current, for every 81XXX-range code your lab bills, is a prerequisite for reimbursement, not an optional compliance step.
| LCD | Coverage Area | Key Requirement |
|---|---|---|
| L35025 | MolDX: Molecular Diagnostic Tests (MDT) | Governs Z-Code requirements for molecular and genetic tests billed in J15. |
| L35062 | Glycated Hemoglobin (HbA1c) | Quarterly for stable; monthly for newly diagnosed. Ohio's high diabetes prevalence makes HbA1c frequency violations common. |
| L35095 | Vitamin D Assay | Documentation of deficiency or at-risk condition required. Routine screening denied. |
| L34752 | Urine Drug Testing | The highest-audit LCD in J15. Both presumptive and definitive drug testing require robust clinical documentation. CGS has issued specific guidance on drug testing medical necessity. |
| L35396 | Tumor Markers | Standard MAC policy; PSA, CEA, CA-125 each with ICD-10 requirements. |
| L35471 | Lipid Testing | Annual screening; quarterly for treatment monitoring. |
| Test | CPT | Frequency Limit |
|---|---|---|
| Urine Drug Screen, presumptive | 80305-80307 | CGS guidance suggests a monthly maximum for most clinical contexts; more frequent testing requires documented clinical justification |
| Definitive Drug Testing | G0480-G0483 | CGS monitors labs billing more than 12 times per year per patient — this triggers medical review |
| HbA1c | 83036 | Quarterly for stable diabetics; more frequent with documentation |
| Lipid Panel | 80061 | Annual screening; quarterly for treatment monitoring |
| Vitamin D | 82306 | Annual; therapeutic monitoring exception with documentation |
Frequency of definitive drug testing per patient — CGS’s single most active review area.
Same-date presumptive and definitive testing billed together without supporting documentation.
Medical necessity documentation for pain management drug panels.
Molecular Z-Code compliance — added to this jurisdiction’s review focus given confirmed MolDX participation.
| Area | Requirement |
|---|---|
| Provider Enrollment | CMS-855B for independent labs. CGS enrollment unit in Nashville. Typical turnaround is 30-60 days. |
| ABN Requirements | Critical for drug testing and for molecular tests without a confirmed Z-Code — CGS requires a documented ABN process for tests ordered outside covered frequency or without supported ICD-10. |
| CLFS / Fee Schedule | CGS publishes quarterly bulletins on CLFS-impacted test rates. Subscribe to the CGS listserv for automatic notification. |
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Yes. J15, administered by CGS Administrators, is a MolDX jurisdiction. Labs billing molecular diagnostic tests in the 81XXX range or most PLA codes must hold an active DEX Z-Code from Palmetto GBA before submitting claims.
The claim is denied automatically. There's no manual override at the claims level, which is why Z-Code registration has to happen before billing.
Kentucky and Ohio. CGS processes J15 claims through the CGS Wizard portal.
Quarterly for stable diabetic patients under LCD L35062. More frequent billing needs documentation of a treatment change or new diagnosis — Ohio's high diabetes prevalence makes this a common denial point.
CMS has proposed merging J15 with J8 into a new 'Jurisdiction Q,' with contract timing staggered between the two. Reverify current status at cms.gov given the time that has elapsed.
CMS-855B, submitted to the CGS enrollment unit in Nashville. Typical turnaround is 30-60 days.
