ApoE at CGS MAC (Nix)

 https://www.cgsmedicare.com/partb/topic/mopath/apoe_coding.html

 ApoE Genotype: Coding and Claim Submission Guidelines

ApoE Genotype: Coding and Claim Submission Guidelines

Apolipoprotein (Apo) E genotype testing was developed to assess the risk of cardiovascular disease. Risk assessment for developing a disease or condition in the absence of signs and symptoms of an illness or injury is not defined as a Medicare benefit. CGS has determined that there is insufficient evidence to support the required clinical utility for ApoE genotype testing as a Medicare benefit category. Accordingly, ApoE Genotype tests are statutorily excluded tests.

The following ApoE tests have been identified as non-covered:

Test
ADmark ApoE Genotype Analysis
ApoE
ApoE Genotyping
Apolipoprotein E (APOE) 2 Mutations, Cardiovascular Risk
Apolipoprotein E Genotyping, Blood
ApoE Genotyping
Apolipoprotein E Genotype Analysis
Apolipoprotein E Genotyping
Apolipoprotein E Genotyping

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 ApoE must include:

• Appropriate CPT code for the test
• 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