MP 2.04.76 Genetic Counseling Medical Policy Section Medicine Issue 12:2013 Original Policy Date 12:2013 Last Review Status/Date Created Local Policy/ 12:2013 Return to Medical Policy Index Disclaimer Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. Description Genetic Counseling involves communications between patients and appropriate medical professionals to provide information and advice to patients who have an actual or potential genetic disease and its possible impact on their family. It is intended to enable patients and their families to make informed medical decisions. Policy Genetic counseling in connection with pregnancy management is medically necessary for evaluation of any of the following: Pregnant women with maternal age 35 years or greater at delivery Parents of a child born with a genetic disorder, birth defect, inborn error of metabolism or chromosome abnormality Pregnant women who, based on prenatal ultrasound tests or an abnormal multiple marker screening test, maternal serum alpha-fetoprotein (AFP) test, test for sickle cell anemia, or tests for other genetic abnormalities have been told their pregnancy may be at increased risk for complications or birth defects Parents of a child with unexplained mental retardation Pregnant women, or women planning pregnancy, exposed to potentially teratogenic, mutagenic or carcinogenic agents
Either parent affected with an autosomal dominant disorder Mother, known or presumed carrier of an X-linked recessive disorder Previous unexplained stillbirth or repeated (three or more) first trimester miscarriages, when there is suspicion of parental or fetal chromosome abnormalities Infertility cases when either parent is known to have a chromosomal abnormality Individuals with primary amenorrhea, azoospermia, abnormal sexual development or failure in developing secondary sexual characteristics Individuals from ethnic groups recognized to be at increased risk for specific genetic disorders Familial cancer disorders Genetic counseling unrelated to pregnancy is medically necessary when provided in conjunction with medically necessary genetic testing, and in acordance with the guidelines of the American College of Medical Genetics (ACMG). Codes Number Description CPT 83890 Molecular diagnostics (DNA) testing often done as part of genetic testing, each nucleic acid type (ie, DNA or RNA) 83891 Molecular diagnostics; isolation or extraction of highly purified nucleic acid, each nucleic acid type (ie, DNA or RNA) 83892 Molecular diagnostics;enzymatic digestion, each enzyme treatment 83893 Molecular diagnostics; dot/slot blot production, each nucleic acid preparation 83894 Molecular diagnostics; separation by gel electrophoresis (eg, agarose, polyacrylamide, each nucleic acid preparation 83896 Molecular diagnostics; nucleic acid probe, each 83897 Molecular diagnostics; nucleic acid transfer (eg, Souther, Northern), each nucleic acid preparation 83898 Molecular diagnostics; amplification, target, each nucleic acid sequence 83900 Molecular diagnostics; amplification, target, multiplex, first two nucleic acid sequences 83901 Molecular diagnostics; amplification, target, multiplex, each additional nucleic acid
sequence beyond 2 (listed separately in addition to code for primary procedure) 83902 Molecular diagnostics; reverse transcription Molecular diagnostics; mutation scanning, by physical properties (eg, single strand conformational polymorphisms (SSCP), 83903 heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA'ase A), single segment,each Molecular diagnostics; mutation identification 83904 by sequencing, single segment, each segment Molecular diagnostics; mutation identification 83905 by allele specific transciption, single segment, each segment Molecular diagnostics; mutation identification 83906 by allele specific translation, sigle segment, each segment Molecular diagnostics; lysis of cells prior to 83907 nucleic acid extraction (eg, stool specimens, paraffin embedded tissue), each specimen Molecular diagnostics; amplification, signal, 83908 each nucleic acid sequence Molecular diagnostics; separation and identification by high resolution technique (eg, 83909 capillary electrophoresis), each nucleic acid preparation 83912 Molecular diagnostics; interpretation and report 83913 Molecular diagnostics; RNA stabilization Mutation identification by enzymatic ligation or primer extension, single segment, each 83914 segment (eg, oligonucleotide ligation assay )OLA), single base chain extension (SBCE), or allele-specific primer extension (ASPE)) Cytogenetics and molecular cytogenetics, 88291 interpretation and report Genetic Testing; chromosome analysis for 88245 breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 88248 cells, count 20 cells, 2 karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X) Chromosome analysis for breakage 88249 syndromes; score 100 cells, clastogen stress
(eg, diepoxybutane, mitomycin C, ionizing radiation, UV radiation) 88261 Chromosome analysis; count 5 cells, 1 karyotype, with banding 88263 Chromosome analysis; count 45 celss for mosaicism, 2 karotypes, with banding 88264 Chrmosome analysis; anayze 20-25 cells Chromosome analysis, amniotic fluid or 88267 chorionic villus, count 15 cells, 1 karyotype, with banding Chromosome analysis, in situ for amniotic fluid 88269 cells, count cells from 6-12 colonies, 1 karyotype, with banding 88271 Molecular cytogenetics; DNA probe, each (eg, FISH) Molecular cytogenetics; chromosomal in situ 88272 hybridization, analyze 3-5 cells (eg, for derivatives and markers) Molecular cytogenetics; chromosomal in situ 88273 hybridization, analyze 10-30 cells (eg, for microdeletions) 88274 Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells 88275 Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells 88280 Chromosome analysis; additional karyotypes, each study 88283 Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) 88285 Chromosome analysis; additional cells counted, each study 88289 Chromosome analysis; additional high resolution study 88291 Cytogenetics and molecular cytogenetics, interpretation and report Medical genetics and genetic counseling 96040 services, each 30 minutes face-to-face with patient/family S0265 Genetic counseling; under physician supervision, each 15 minutes S3800 Genetic testing for amyotrophic lateral sclerosis (ALS) S3818 Genetic testing; Complete gene sequence analysis; BRCA 1 gene
S3819 S3820 S3822 S3823 S3828 S3829 S3830 S3831 S3833 S3834 S3835 S3837 S3840 S3841 S3842 S3843 S3844 S3845 S3846 Complete gene sequence analysis; BRCA 2 gene Complete analysis BRCA 1 and BRCA 2 gene sequence analysis for susceptibility to breast and ovarian cancer Single mutation analysis (in individual with a known BRCA1 of BRCA2 mutation in the family) for susceptibility to breast and ovarian cancer Three-mutation BRCA1 and BRCA2 analysis for susceptibility to breast and ovarian cancer in Ashkenazi individuals Complete gene sequence analysis; MLH1 gene Complete gene sequence analysis; MLH2 gene Complete MLH1 and MLH2 gene sequence analysis for hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing Single-mutation analysis (in individual with a known MLH1 and MLH2 mutation in the family) for hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing Complete APC gene sequence analysis for susceptibility to familial adenomatous polyposis (FAP) and attenuated fap Single-mutation analysis (in individual with a known APC mutation in the family) for susceptibility to familial adenomatous polyposis (FAP) and attenuated FAP Complete gene sequence analysis for cystic fibrosis genetic testing Complete gene sequence analysis for hemochromatosis genetic testing DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to multiple endocrine neoplasia type 2 Genetic testing for retinoblastoma Genetic testing for Von Hippel-Lindau disease DNA analysis of the F5 gene for susceptibility to factor V Leiden thrombophilia DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital, profound deafness Genetic testing for alpha-thalassemia Genetic testing for hemoglobin E betathalassemia
ICD-9 Diagnosis S3847 S3848 S3849 S3850 S3851 S3852 S3853 S3854 S3855 multiple codes Genetic testing for Tay-Sachs disease Genetic testing for Gaucher disease Genetic testing for Neimann-Pick disease Genetic testing for sickle cell anemia Genetic testing for Canavan disease DNA analysis for APOE epilson 4 allele for susceptibility to Alzheimer's disease Genetic testing for myotonic muscular dystrophy Gene expression profiling panel for use in the management of breast cancer treatment Genetic testing for detection of mutations in the presenilin-1 gene