March 22, 2013
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing: Coding and Claim Submission Guidelines
ARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes, and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. CGS has determined that testing for ARVD/C does not support the required clinical utility for the established Medicare benefit category and is a statutorily excluded test.
The following ARVD/C test has been identified as non-covered:
Test |
---|
ARVC Sequencing Panel |
Health care providers are not required to submit claims to Medicare for statutorily non-covered services; however, you may choose to submit claims (e.g., at the patient's request). Claims for ARVC sequencing panels must include:
- For dates of service prior to January 1, 2013: use the appropriate CPT code stack for the test
- For dates of service on or after January 1, 2013: CPT code 81479
- HCPCS modifier GY (statutorily non-covered service)
- The appropriate ICD-9-CM code(s)
- The name of the test (ARVC sequencing panel):
- Electronic claims: Loop 2400, NTE02, or SV101-7 field
- Paper claims: Box 19
Reference:
- Definition of "reasonable and medically necessary": Social Security Act, section 1862(a)(1)(A)
- Exception to mandatory claim submission for "categorically excluded services": CMS MLN Matters article SE0908, "Mandatory Claims Submission and Its Enforcement"
- Guidance on issuing Advance Beneficiary Notices of Noncoverage (ABNs) on a voluntary basis for statutorily excluded services: CMS Beneficiary Notices Initiative webpage – Fee-For-Service (FFS) ABN