ApoE Genotype: Coding and Claim Submission Guidelines
Apolipoprotein (Apo) E genotype testing was developed to assess the risk of cardiovascular disease. Risk assessment for developing a disease or condition in the absence of signs and symptoms of an illness or injury is not defined as a Medicare benefit. CGS has determined that there is insufficient evidence to support the required clinical utility for ApoE genotype testing as a Medicare benefit category. Accordingly, ApoE Genotype tests are statutorily excluded tests.
The following ApoE tests have been identified as non-covered:
Test |
---|
ADmark ApoE Genotype Analysis |
ApoE |
ApoE Genotyping |
Apolipoprotein E (APOE) 2 Mutations, Cardiovascular Risk |
Apolipoprotein E Genotyping, Blood |
ApoE Genotyping |
Apolipoprotein E Genotype Analysis |
Apolipoprotein E Genotyping |
Apolipoprotein E Genotyping |
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 ApoE must include:
- Appropriate CPT code for the test
- HCPCS modifier GY (statutorily non-covered service)
- The appropriate ICD-9-CM code(s)
- The name of the test:
- Electronic claims: Loop 2400, NTE02, or SV101-7 field
- Paper claims: Block 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 Web page – Fee-For-Service (FFS) ABN