Skip to Main Content

Print | Bookmark | Font Size: + |

April 5, 2013

Fragile X Coding and Billing Guidelines

Effective for dates of service (DOS) on and after January 1, 2013.

CGS Administrators 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

To receive a Fragile X service denial, please submit the following claim information:

  • Select the appropriate CPT code 81243, 81244 for the test (effective DOS January 1, 2013)
  • Append with GA HCPCS modifier to indicate a valid Advance Beneficiary Notice (ABN) is on file for the service
  • Select the appropriate diagnosis for the patient

Reference:

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved