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April 11, 2013

FANCC Genetic Testing: Coding and Claim Submission Guidelines

FANCC gene testing is performed in association with Fanconi anemia (FA), a condition characterized by physical abnormalities, bone marrow failure, and increased risk of malignancy. For infants and children, FANCC genetic testing is used to confirm the clinical findings, such as blood counts and bone marrow biopsy, to diagnose FA. Genetic testing for adults is used to screen potential carriers of the mutation. Therefore, CGS Administrators has determined that testing for the FANCC 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 FANCC gene.

The following tests have been identified as non-covered:

Test
Fanconi's Anemia DNA Mutation Analysis
Fanconi Anemia, Group C (FANCC) 2 Mutations
Fanconi Anemia, Group C (FANCC) 2 Mutations, Fetal
Fanconi Anemia C Mutation Analysis, IVS4(+4)A->T and 322delG

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 FANCC 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 81242
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:

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")

FANCC Genetic Testing: Coding and Claim Submission Guidelines

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