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April 11, 2013

GBA Genetic Testing: Coding and Claim Submission Guidelines

Mutations found in glucosidase, beta, acid (GBA) are associated with Gaucher disease (GD), which encompasses a continuum of clinical findings. Since GBA genetic testing is used to confirm the clinical findings to diagnose GD, CGS Administrators has determined that GBA genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, CGS will also deny panels of tests that include the GBA gene as statutorily excluded services.

The following tests have been identified as non-covered:

Test

Gaucher Disease DNA Mutation

Gaucher (GBA) 8 Mutations

Gaucher (GBA) 8 Mutations, Fetal

Gaucher Disease, Mutation Analysis, GBA

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 GBA genetic testing must include:

  • For dates of service prior to January 1, 2013: use the appropriate CPT code stack for the test
  • For dates of service on or after January 1, 2013: CPT code 81251
  • HCPCS modifier GY (statutorily non-covered service)
  • The appropriate ICD-9-CM code(s)
  • The name of the test:
    • Electronic claims: Loop 2400, NTE02, or SV101-7 field
    • Paper claims: Box 19

Reference:

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