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April 11, 2013

Fragile X Testing: Coding and Claim Submission Guidelines

CGS 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

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 Fragile X testing must include:

  • CPT code 81243 or 81244 (effective DOS January 1, 2013)
  • 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:

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