January 23, 2015
GeneSight: Coding and Claims Submission Guidelines
Effective for services performed on or after 10/24/2014, coverage requirements for this test are addressed in CGS's Local Coverage Determination (LCD) for MoPath: GeneSight Assay for Refractory Depression (L35437). The instructions in this article apply to services provided from 01/01/2014 through 10/23/2014.
GeneSight® Psychotropic is a multiplex pharmacogenomic test involving the analysis of 50 alleles (SNPs) from six different genes and a clinical outcomes-based decision support modeling tool that weights the influence of the various alleles/SNPs with respect to 32 different psychotropic pharmaceutical agents. The test results in the differentiation of psychoactive drugs that are likely to be effective and well-tolerated by a particular patient versus those that are not.
GeneSight® testing may only be ordered by licensed psychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) (in accordance with DSM IV/V criteria) who are suffering with refractory moderate to severe depression (as defined by the 17-item Hamilton Rating Scale for Depression (HAM-D17) score of 14 or greater) after at least one prior neuropsychiatric medication failure.
Claims for GeneSight tests must include:
- CPT code 81479
- The appropriate ICD-9-CM code(s):
- 296.20 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED DEGREE
- 296.22 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MODERATE DEGREE
- 296.23 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
- 296.24 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
- 296.25 MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
- 296.30 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE
- 296.32 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE
- 296.33 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR
- 296.34 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR
- 296.35 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION
- 311 DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED
- The name of the test (GeneSight):
- Electronic claims: Loop 2400, NTE02, or SV101-7 field
- Paper claims: Box 19