April 11, 2013
FANCC Genetic Testing: Coding and Claim Submission Guidelines
FANCC gene testing is performed in association with Fanconi anemia (FA), a condition characterized by physical abnormalities, bone marrow failure, and increased risk of malignancy. For infants and children, FANCC genetic testing is used to confirm the clinical findings, such as blood counts and bone marrow biopsy, to diagnose FA. Genetic testing for adults is used to screen potential carriers of the mutation. Therefore, CGS Administrators has determined that testing for the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, CGS will also deny panels of tests that include the FANCC gene.
The following tests have been identified as non-covered:
Test |
---|
Fanconi's Anemia DNA Mutation Analysis |
Fanconi Anemia, Group C (FANCC) 2 Mutations |
Fanconi Anemia, Group C (FANCC) 2 Mutations, Fetal |
Fanconi Anemia C Mutation Analysis, IVS4(+4)A->T and 322delG |
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 FANCC genetic testing 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 81242
- 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: 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 Web page – Fee-For-Service (FFS) ABN