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:
- 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


