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November 13, 2014

BRCA1 and BRACA2 Gene Tests: Coding and Claim Submission Guidelines

CGS is retiring this MoPath article effective 04/09/15.

Based on the vignettes published in the 2012 CPT Changes: An Insider's View, CPT codes 81215 and 81217 describe tests to determine if the patient carries the familial mutation. Carrier testing to identify risk for disease, without signs and symptoms of disease, is not a Medicare benefit. Therefore, effective for dates of service on or after December 29, 2014, BRCA1 and BRCA2 genetic testing for a familial mutation, submitted with CPT codes 81215 and 81217, will be denied as statutorily excluded services. In addition to single gene testing, CGS will also deny panels of tests that include the interrogation of BRCA1 and/or BRCA2 familial testing as statutorily excluded services.

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 CPT codes 81215 and 81217 must include:

  • CPT code 81215 (BRCA1, known familial variant) or 81217 (BRCA2, known familial variant), as appropriate
  • HCPCS modifier GY
  • The appropriate ICD-9 code(s)
  • The name of the test (either BRCA1 or BRCA2 gene test):
    • Electronic claims: Loop 2400 or SV101-7
    • 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 SE0908External PDF, "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 pageExternal website – Fee-For-Service (FFS) ABN

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