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April 5, 2013

BLM Gene Analysis Coding and Billing Guidelines

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

The clinical diagnosis of Bloom (BLM syndrome (BSyn), characterized by severe pre and postnatal growth deficiency, highly characteristic sparseness of subcutaneous fat tissue in infants and children, is confirmed through cytogenetic testing. Molecular genetic testing identifies BLM gene mutation carriers at risk for conceiving offspring with the disease. Therefore, BLM genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, CGS Administrators will also deny panels of tests that include the BLM gene as a statutorily excluded service.

The following tests have been identified as non-covered:

Test

Bloom (BLM) 2281del6/ins7 Mutation

Bloom (BLM) 2281del6/ins7 Mutation, Fetal

BLOOM SYNDROME DNA MUTAT

Bloom Syndrome, Mutation Analysis, 2281del6/ins7

Ashkenazi Jewish FlexPanel

Ashkenazi Jewish FlexPanel

Ashkenazi Jewish Diseases (BLM, ASPA, IKBKAP, FANCC, GBA, MCOLN1, SMPD1, HEXA)

To receive a BLM gene test service denial, please submit the following claim information:

  • CPT code 81209 (effective 01/01/2013)
  • 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
  • Enter the appropriate identifier adjacent to each code in the stack in the comment/narrative field for the following claim field/types:
    • Loop 2400, NTE02, or SV101-7 for the 5010A1 837P
    • Box 19 for 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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