- 4009 Hackney Springs Ln, Sachse, TX 75048
| STATES / TERRITORIES | PHONE · PORTAL | CLAIM VOLUME | BENEFICIARIES |
|---|---|---|---|
| 1-855-252-8782 · Novitasphere JL | ~200 million claims/year | ~3.4 million Medicare FFS |
Novitas Solutions does not participate in the MolDX program for JH. Labs billing molecular diagnostic tests, CPT codes in the 81XXX range, or most PLA codes do not need a Palmetto GBA DEX Z-Code to submit those claims; they bill under standard CPT/ICD-10 coding per the applicable LCD instead.
NGS applies LCD L34067 — Molecular Pathology Procedures — to Tier 1 and Tier 2 molecular pathology codes billed in J6. Each code carries its own indication requirements, and labs must validate ICD-10 linkage per test even though no Z-Code applies. Confirm the current LCD text through NGS’s Medicare Coverage Database search before relying on it in a compliance decision.
| LCD | Coverage Area | Key Requirement |
|---|---|---|
| L34067 | Molecular Pathology Procedures | Standard (non-MolDX) LCD covering Tier 1 and Tier 2 molecular pathology tests with specific indication requirements for each code. Labs must validate ICD-10 linkage per test; no Z-Code required. |
| L35062 | Glycated Hemoglobin (HbA1c) | Quarterly coverage for stable diabetics; monthly for newly diagnosed or treatment-change patients. Shared LCD numbering across NGS jurisdictions (J6 and JK). |
| L35114 | Serum Iron Studies | Coverage for iron deficiency (D50.x), anemia workup, and chronic disease monitoring. |
| L35396 | Tumor Markers — PSA, CEA, AFP, CA-125, CA 19-9 | Each carries its own ICD-10 requirements. Chicago-area oncology lab volume makes this a high-risk category. |
| L34552 | Infectious Disease Testing | Covers HIV, HCV, HBV antibody/antigen testing for specific risk indications; not covered as routine annual wellness testing. |
| Test | CPT | Frequency Limit |
|---|---|---|
| HbA1c | 83036 | Quarterly for stable diabetics; monthly for unstable or newly diagnosed patients |
| CBC with Differential | 85025 | No frequency restriction, but medical necessity documentation is required for repeat testing |
| PSA | 84153 | Annual monitoring for known prostate cancer; billed with the appropriate ICD-10 for diagnostic testing |
| Hepatitis Panels (HBV/HCV/HIV serologies) | L34552 panel codes | Covered once per episode for new diagnoses; follow-up testing per treatment context |
| Lipid Panel | 80061 | Annual screening; quarterly for treatment monitoring |
Molecular diagnostics coding — Tier 1 vs. Tier 2 assignment under L34067, one of the most frequent denial sources in the jurisdiction.
Tumor marker ICD-10 linkage — PSA, CEA, AFP, CA-125, and CA 19-9 billed without the diagnosis each code requires, concentrated in the Chicago-area oncology market.
Infectious disease panel billing — HIV/HCV/HBV testing billed as routine wellness screening rather than for a documented risk indication.
labs serving home health patients should verify whether their ordering provider is affiliated with an HH agency that reports to a different MAC.
| Area | Requirement |
|---|---|
| Provider Enrollment | CMS-855B for independent labs, submitted to NGS provider enrollment (Indianapolis, IN). EDI enrollment is also required for electronic claim submission through iCS. |
| ABN Requirements | Standard CMS-R-131. NGS publishes specific ABN guidance for molecular testing — review NGS education articles on ngsmedicare.com before finalizing your ABN workflow. |
| CLFS / Fee Schedule | Annual CLFS updates affect the full lab fee schedule. NGS typically publishes CLFS implementation guidance in Q4 of each year — build that into your annual rate audit. |
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No. NGS does not participate in the MolDX program for J6. Labs billing molecular diagnostic tests in the 81XXX range or most PLA codes bill under standard CPT/ICD-10 coding per LCD L34067 — no Palmetto GBA DEX Z-Code is required or accepted.
It's billed with standard CPT/ICD-10 coding under LCD L34067, with each Tier 1 or Tier 2 code (81105–81479) mapped to the correct clinical indication. Getting that tier assignment wrong — not a missing Z-Code — is the most common reason these claims get denied in J6.
Illinois, Minnesota, and Wisconsin. NGS processes J6 (and JK) claims through the iCS portal.
Quarterly for stable diabetic patients, consistent with NGS's Glycated Hemoglobin coverage policy (LCD L35062). More frequent billing needs documentation of a treatment change or new diagnosis.
CMS proposed merging J6 with J5 into a new “Jurisdiction G” as of a June 2025 review, with no confirmed implementation date at that time. More than a year has since passed, so reverify current status directly at cms.gov before relying on this.
CMS-855B for independent labs, submitted to NGS provider enrollment. Hospital outpatient labs use CMS-855A instead.
