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Article Title
Billing and Coding: MolDX: FANCC Genetic Testing
Article Type
Billing and Coding
AMA CPT / ADA CDT / AHA NUBC Copyright Statement
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
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CMS National Coverage Policy
Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member.
Article Guidance
Article Text
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, the MolDX Team has determined that testing for the FANCC is
not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the FANCC gene.
To receive a FANCC test denial, please submit the following claim information:
• CPT® code 81242- FANCC, common variant
• CPT® code 81412 Ashkenazi Jewish Associated Disorder
• CPT® code 81443 Genetic testing for severe inherited conditions
• An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
• For a voluntary issued ABN, append with GX modifier
• To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
• For CPT® non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
• Enter the appropriate DEX-Z-Code identifier adjacent to the CPT® code in the comment/narrative field for the following Part B claim field/types:
♦ Loop 2400 or SV101-7 for the 5010A1 837P
♦ Item 19 for paper claim
• Enter the appropriate DEX-Z-Code identifier adjacent to each code in the comment/narrative filed for the following Part A claim field types:
1
♦ Line SV202-7 for 837I electronic claim
♦ Block 80 for the UB04 claim form
Coding Information
CPT/HCPCS Codes
Expand All | Collapse All
Group 1
(1 Code)
Group 1 Paragraph
N/A
Group 1 Codes
Code Description
81242 FANCC (FANCONI ANEMIA, COMPLEMENTATION GROUP C) (EG, FANCONI ANEMIA, TYPE C) GENE ANALYSIS, COMMON VARIANT (EG, IVS4+4A
Group 2
(2 Codes)
Group 2 Paragraph
CPT® codes that are also referenced in other articles.
Group 2 Codes
Code Description
81412 ASHKENAZI JEWISH ASSOCIATED DISORDERS (EG, BLOOM SYNDROME, CANAVAN DISEASE, CYSTIC FIBROSIS, FAMILIAL DYSAUTONOMIA, FANCONI ANEMIA GROUP C, GAUCHER DISEASE, TAY-SA
SEQUENCING OF AT LEAST 9 GENES, INCLUDING ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, AND SMPD1
81443 GENETIC TESTING FOR SEVERE INHERITED CONDITIONS (EG, CYSTIC FIBROSIS, ASHKENAZI JEWISH-ASSOCIATED DISORDERS [EG, BLOOM SYNDROME, CANAVAN DISEASE, FANCONI ANEMIA TYPE
BETA HEMOGLOBINOPATHIES, PHENYLKETONURIA, GALACTOSEMIA), GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 15 GENES (EG, ACADM, ARSA, ASPA, ATP
GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)
CPT/HCPCS Modifiers
Expand All | Collapse All
Group 1
(2 Codes)
Group 1 Paragraph
N/A
Group 1 Codes
Code Description
2
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CON
ICD-10-CM Codes that Support Medical Necessity
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Group 1
Group 1 Paragraph
N/A
Group 1 Codes
N/A
ICD-10-CM Codes that DO NOT Support Medical Necessity
Expand All | Collapse All
Group 1
Group 1 Paragraph
N/A
Group 1 Codes
N/A
ICD-10-PCS Codes
Expand All | Collapse All
Group 1
Group 1 Paragraph
N/A
Group 1 Codes
N/A
Additional ICD-10 Information
N/A
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types
indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.
N/A
3
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other
Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.
N/A
N/A
Other Coding Information
Expand All | Collapse All
Group 1
Group 1 Paragraph
N/A
Group 1 Codes
N/A
Revision History Information
Revision History Revision History
Date Number Revision History Explanation
12/17/2021 R3 Noridian has modified certain language in this article to mirror the language used presently by the MolDX team at Palmetto GBA as part of an annual review. Revision history dates and language may not exactly
guidance.
12.01.2019: This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual. Title XVIII of the Social Security Act, §1862(a)(1)(A) has been a
Under Article Title changed title from MolDX: FANCC Genetic Testing Coding and Billing Guidelines to Billing and Coding: MolDX: FANCC Genetic Testing . Under Article Text deleted the sentence S
CPT® codes 81412 and 81443. Under CPT/HCPCS Codes Group 2: Paragraph added verbiage CPT® codes that are also referenced in other articles. Under CPT/HCPCS Codes Group 2: Codes added CPT®
01.01.2019: Added 81412 and 81443 to the article. Added 81242, 81412, and 81443 to the CPT/HCPCS Group 1 section. This is due to the 2019 Annual CPT/HCPCS Code update and is effective 1/1/19.
12/01/2019 R2 As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.
References were added to the CMS National Coverage Policy Section.
CPT codes 81412 and 81443 were moved from Group 1 to Group 2
01/01/2019 R1 Article is revised to add CPT codes 81412 and 81443 per the 2019 Annual CPT Code Update. Added Part A claim filing information.
Associated Documents
Related Local Coverage Documents
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Related National Coverage Documents
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
02/24/2022 12/17/2021 - N/A Currently in Effect
