October 27, 2015
4q25-AF Risk Genotype Coding and Billing Guidelines (CM00069)
Effective for dates of services on and after 06/14/2012.
The 4q25-AF Risk Genotype Test was developed to help predict the risk of atrial fibrillation and cardioembolic stroke. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category.
As reviewed, the developer described the indication to perform a 4q25-AF Risk Genotype Test as a risk assessment for developing a disease or condition. Risk assessment for developing a disease or condition in the absence of signs and symptoms of an illness or injury is also not defined as a Medicare benefit.
Therefore, the 4q25-AF Risk Genotype Test would continue to be a statutory excluded service.
To receive a 4q25-AF Risk genotype service denial, please submit the following claim information:
- CPT code 81479 – Unlisted molecular pathology procedure
- An Advance Beneficiary Notice of Non-Coverage (ABN)
is not required for statutorily excluded services.
- For a voluntary issued ABN, append with HCPCS modifier GX
- To indicate a valid ABN is on file for a known statutorily excluded service, append with HCPCS modifier GY
- Select the appropriate diagnosis for the patient
- Enter the appropriate identifier adjacent to the CPT code in the comment/narrative field for the following claim field/types:
- Part A: Loop 2300 NTE 01 (electronic claim); Form Locator 80 (paper claim)
- Part B: Loop 2400 or SV101-7 (electronic claim); Item 19 (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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