Cytogenomic Constitutional Microarray Analysis Coding and Billing Guidelines (CM00044)
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IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.
Content provided on this page contains outdated information and instruction and should not be considered current. CGS is providing this archived information for research purposes only. This archived section contains previously issued instructions that have since been updated or are no longer applicable for Medicare billing purposes.

October 20, 2015 - Retired 04.21.16

Cytogenomic Constitutional Microarray Analysis Coding and Billing Guidelines (CM00044)

MolDX has determined that cytogenomic constitutional microarray analysis is not a Medicare covered service. Screening in the absence of signs and symptoms of an illness or injury is not defined as a Medicare benefit. Therefore, MolDX will deny cytogenomic constitutional microarray analysis as a statutorily excluded service.

To receive a cytogenomic constitutional microarray analysis service denial, please submit the following claim information:

Appropriate CPT code 81228 or 81229

An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services

For a voluntary issued ABN, append with GX modifier

To indicate a statutorily excluded service, append with a GY modifier

Select the appropriate diagnosis for the patient

Enter the appropriate Identifier adjacent to each code in the stack in the comment/narrative field for the following claim field/types:

Loop 2300 NTE01 for Part A or Loop 2400 or SV101-7 for the 5010A1 837P for Part B

Form locator 80 for Part A or Box 19 for Part B paper claim

Reference: Sec. 1862 (1)(A) Statutory Exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,…"


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