April 11, 2013
Fragile X Testing: Coding and Claim Submission Guidelines
CGS has determined that Fragile X testing 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, CGS Administrators will deny testing for Fragile X as a statutorily excluded service.
The following Fragile X tests have been identified as non-covered:
Test |
2013 CPT Code |
---|---|
Fragile X DNA Test |
81243 |
Fragile X DNA Analysis Fetus |
81243 |
Fragile X (FMR1) Diagnostic |
81244 |
Fragile X (FMR1) Diagnostic, Fetal |
81244 |
Fragile X Syndrome, Molecular Analysis |
81244 |
Fragile X - Screen |
81243 |
Fragile X - Diagnostic |
81244 |
Fragile X (PCR with reflex to Southern Blot) |
81244 |
Fragile X Syndrome DNA Analysis |
81244 |
Fragile X by DNA analysis |
81244 |
Fragile X DNA analysis |
81243 |
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 Fragile X testing must include:
- CPT code 81243 or 81244 (effective DOS January 1, 2013)
- 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