August 5, 2013
CHD7 Gene Analysis: Coding and Claim Submission Guidelines
These instructions are effective for dates of service on and after June 26, 2013.
CHD7 gene testing may be performed during the diagnosis of CHARGE Syndrome. Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, CGS has determined that CHD7 gene analysis is a statutorily excluded service. CGS will also deny tests that include one or more of CHD7 tests reported with CPT code 81479 as statutorily excluded services.
The following CHD7 test has been identified as non-covered:
| Test | CPT Code |
|---|---|
| CHD7 Gene Sequencing | 81479 |
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 CHD7 gene analysis must include:
- Appropriate CPT code per description (effective 01/01/2013)
- CPT code 81407: full gene sequencing
- CPT code 81479: all other CHD7 testing
- HCPCS modifier GY (statutorily non-covered service)
- The appropriate ICD-9-CM code(s)
- For CPT code 81479, submit the name of the test (used for all other CHD7 testing not included in CPT code 81407):
- 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
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