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April 11, 2013

Cytogenomic Constitutional Microarray Analysis: Coding and Claim Submission Guidelines

CGS has determined that cytogenomic constitutional microarray analysis 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 will deny cytogenomic constitutional microarray analysis as a statutorily excluded service.

The following cytogenomic constitutional microarray analysis services have been identified as non-covered:

Test
Cytogenomic SNP Microarray
Cytogenomic SNP Microarray Buccal Swab
Genomic Alterations, Prenatal, Clarisure Oligo-SNP Array
Genomic Alterations, Postnatal, ClariSure(R) Oligo-SNP (Follow-up)
Signature PrenatalChip®OS + SNP - Cultured Amnio/CVS
Signature PrenatalChip®OS + SNP - Direct Amnio/CVS
Signature PrenatalChip®TE + SNP - Culture Amnio/CVS
Signature PrenatalChip®TE + SNP - Direct Products of Conception or Tissue
Signature PrenatalChip®TE +SNP - Prenatal blood
Signature PrenatalChip®TES + SNP - DNA
SignatureChipOS® + SNP - DNA
SignatureChipOS® + SNP - Peripheral Blood
SNP Array CGH

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 cytogenomic constitutional microarray analysis must include:

For dates of service prior to January 1, 2013: appropriate CPT code(s) for the test
For dates of service on or after January 1, 2013: CPT code 81228 or 81229
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: 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 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

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Cytogenomic Constitutional Microarray Analysis: Coding and Claim Submission Guidelines

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