Section Genetic Services 23 - TMHP · 23.3.2.2 Psychosocial Genetic Counseling Initial psychosocial...

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Section 23 23Genetic Services 23.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2 23.1.1 STAR and STAR+PLUS Program Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2 23.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2 23.3 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2 23.3.1 Genetic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2 23.3.1.1 Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3 23.3.1.2 Medical Genetics Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . 23-3 23.3.1.3 Psychosocial Genetic Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3 23.3.2 Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3 23.3.2.1 Medical Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3 23.3.2.2 Psychosocial Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3 23.3.3 Cytogenetic Tests Reimbursed to Providers. . . . . . . . . . . . . . . . . . . . . . . . . . 23-4 23.3.4 Genetic Benefit Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-4 23.3.4.1 Genetic Evaluation and Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-4 23.3.4.2 Genetic Diagnostic and Laboratory Procedures . . . . . . . . . . . . . . . . . . 23-4 23.3.4.3 Genetic DNA Testing and Laboratory Enzyme Tests . . . . . . . . . . . . . . . 23-6 23.3.4.4 Genetic Ultrasound Testing Procedures . . . . . . . . . . . . . . . . . . . . . . . 23-12 23.4 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-13 23.4.1 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-13

Transcript of Section Genetic Services 23 - TMHP · 23.3.2.2 Psychosocial Genetic Counseling Initial psychosocial...

S e c t i o n

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23Genetic Services

23.1 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-223.1.1 STAR and STAR+PLUS Program Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2

23.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2

23.3 Benefits and Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-223.3.1 Genetic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-2

23.3.1.1 Health History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-323.3.1.2 Medical Genetics Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . 23-323.3.1.3 Psychosocial Genetic Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3

23.3.2 Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-323.3.2.1 Medical Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-323.3.2.2 Psychosocial Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-3

23.3.3 Cytogenetic Tests Reimbursed to Providers. . . . . . . . . . . . . . . . . . . . . . . . . . 23-423.3.4 Genetic Benefit Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-4

23.3.4.1 Genetic Evaluation and Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-423.3.4.2 Genetic Diagnostic and Laboratory Procedures . . . . . . . . . . . . . . . . . . 23-423.3.4.3 Genetic DNA Testing and Laboratory Enzyme Tests . . . . . . . . . . . . . . . 23-623.3.4.4 Genetic Ultrasound Testing Procedures . . . . . . . . . . . . . . . . . . . . . . . 23-12

23.4 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-1323.4.1 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-13

Section 23

23.1 EnrollmentOnly full-service genetic providers may enroll in the Texas Medicaid Program. Before enrolling, the provider must contract with the Department of State Health Services (DSHS), for the provision of genetic services. Basic contract requirements are as follows:

• The provider’s medical director must be a clinical genet-icist (MD or DO) who is board eligible/certified by the American Board of Medical Geneticists (ABMG). The physician must oversee the delivery and content of all medical services.

• The provider must use a team of professionals to provide genetic evaluative, diagnostic, and counseling services. The team rendering the services must consist of the following professional staff: a clinical geneticist (MD or DO) and at least one of the following; nurse, social worker, medical geneticist (Ph.D.), or genetic counselor.

The provider’s clinical laboratory (if it has a clinical laboratory) must have received federal Clinical Laboratory Improvement Amendments (CLIA) accreditation from the Centers for Medicare & Medicaid Services (CMS) and must be Medicare-approved. If the provider does not have a clinical laboratory, then the laboratory or laboratories it uses must have at least the same credentials.

Genetic services are administrated through the DSHS Health Screening Branch. A genetic provider wishing to enroll should contact TMHP, which in turn contacts the DSHS Health Screening Branch. DSHS sends a contract application to the interested provider, which should be completed and returned to DSHS. DSHS evaluates the application, and if approved, notifies TMHP to enroll the provider.

For more information, contact:

DSHS Health Screening Branch1100 West 49th Street, MC 1918

Austin, TX 78756-31991-512-458-7111, Ext. 2193

TMHP will issue a genetic provider vendor number for genetic services to the provider. Additionally, each genetic professional providing clinical services must obtain a performing Texas Provider Identifier (TPI) from TMHP at the following address:

Texas Medicaid & Healthcare PartnershipProvider Enrollment

PO Box 200795Austin, TX 78720-0795

A provider cannot be enrolled if his or her license is due to expire within 30 days; a current license must be submitted.

Refer to: “Provider Enrollment” on page 1-2 for more information about enrollment procedures.

“Clinical Laboratory Improvement Amendments (CLIA)” on page 27-2.

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23.1.1 STAR and STAR+PLUS Program EnrollmentCertain providers may be required to enroll with a Medicaid Managed Care health plan to be reimbursed for services provided to Medicaid Managed Care clients. Contact the individual health plan for enrollment infor-mation.

Refer to: Section 7, Managed Care for more information on Medicaid Managed Care programs.

23.2 ReimbursementGenetic providers are reimbursed according to the estab-lished allowable maximum fee schedule.

TMHP manually prices genetic laboratory services that have no established fee.

Clinical laboratory services billed by a genetic services provider are reimbursed according to reimbursement methodology for these services in accordance with Title 1 Texas Administrative Code (TAC) §§355.8081 and §§355.8610, and the Deficit Reduction Act of 1984 (DEFRA).

Refer to: “Reimbursement” on page 2-2 for more infor-mation about reimbursement.

23.3 Benefits and LimitationsGenetic providers are reimbursed for the provision of genetic services to evaluate clients about the possibility of a genetic disorder, diagnose such disorders, counsel clients regarding such disorders and their implications for family planning, and provide follow up of clients with known or suspected disorders. These services must be prescribed by a physician (MD, DO) and performed by or under the supervision of a clinical geneticist (MD, DO). These services may include genetic history and physical examination, psychosocial genetic assessment, laboratory services and echography, radiological services, diagnostic procedures, and counseling.

The following services are not allowed:

• Genetic services for conditions that usually have no serious psychosocial or medical implications for a client

• Prenatal diagnosis for sex determination of the fetus only, without implications for genetic disease

• Genetic services provided to clients eligible for emergency care only

23.3.1 Genetic EvaluationThe genetic evaluation consists of health history, medical genetics physical examination, and psychosocial genetic assessment.

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23.3.1.1 Health HistoryDetailed family genetic history. The interviewer meets with the family to gather extensive medical and family history covering four matriarchal and patriarchal generations. A pedigree is constructed. This history includes any affected individuals in the immediate or extended family, infor-mation on pregnancy, plus a developmental, educational, and social history.

Genetic Health History Update. This is performed to update the health history. It consists of noting changes, such as the loss of eyesight or change in muscle control, in the health of the client under evaluation. Genetic-related problems identified in newborns or in other family members should also be included in the interval history update.

23.3.1.2 Medical Genetics Physical ExaminationThis examination varies according to specific client needs, but typically consists of extensive anthropomorphic measurements, including occipital frontal circumference, height, weight, and measurement of inner canthal and outer canthal distances with calculations of interpupillary distances; ear size and ear placement on the head; philtrum length; internipple distance; and finger and palm lengths. The physical examination itself usually entails examination of:

• The head

• The eyes, including funduscopic examination

• The nose, mouth, and oral pharynx

• The ears, including assessment of tympanic membranes

• The neck, including assessment of thyroid gland size

• The chest, including breasts and heart

• The abdomen, including assessment for organ size and assessment for abnormal masses

• Genitalia, and often measurement of size of genital components

• The back

• The extremities, including specific measurement of any joint limitations

• The skin for abnormalities, which often includes Woods light examination for fluorescent depigmented areas

• Neurological assessment, including cranial nerve examination, examination of deep tendon reflexes, and cerebellar and long track motor functions

Photographs are also taken of the client, AP and lateral, both face and total body. Additional photographs are taken of any abnormalities noted upon physical exami-nation for further consultative work and review.

• Physical Examination (Standard). The examination is appropriate for follow-up examinations.

• Physical Examination (Complex). This examination is applicable for referred clients in whom genetic diseases of a more complex nature are suspected or partially confirmed.

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• Physical Examination (Comprehensive). This exami-nation is used for referred clients in whom complex genetic diseases are suspected that require complete and extensive workup. This examination includes the completion of all tasks outlined in the section on the medical genetic physical examination and requires extensive time to make a diagnosis and disposition.

23.3.1.3 Psychosocial Genetic Assessment• Standard. A detailed social history related to the stated

reason for referral is obtained to assess family dynamics and psychosocial functioning. The client’s primary psychosocial problems and needs are evaluated.

• Complex. Clients may receive additional counseling services when more severe family or individual dysfunction is evident as related to the primary reason for referral.

23.3.2 Genetic CounselingGenetic counseling consists of medical genetic and psychosocial genetic counseling.

23.3.2.1 Medical Genetic Counseling• Prenatal Counseling. Includes a review of all information

obtained in the health history, detailed family genetic history and pedigree construction, as well as the diagnosis established after completion of the medical genetic physical examination. The family is counseled as to how the prenatal diagnosis applies to their case regarding the recurrence risks as well as prenatal diagnostic procedures.

• Medical Genetic Counseling. The family is advised of the results of the health history, detailed family genetic history and pedigree construction, and the nature of the diagnosis. It is the counselor’s responsibility to explain the diagnosis and establish the implications for the affected individual, immediate family, and extended family. This counseling includes prognosis, recurrence risks, family planning implication, and the options available to family members who are at increased risk for giving birth to individuals with the same condition.

• Follow-up Genetic Counseling. Conducted to review the medical genetic counseling results and provide additional information as indicated.

23.3.2.2 Psychosocial Genetic CounselingInitial psychosocial genetic counseling. Client reactions relating to the genetic disorder are explored and a practical plan of action concerning the client and the family is formulated using the information obtained from the interpretation of the genetic assessment.

Follow-up psychosocial genetic counseling. Conducted to review the psychosocial genetic counseling and provide additional information as indicated.

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23.3.3 Cytogenetic Tests Reimbursed to ProvidersCertain cytogenetic tests may be reimbursed as a type of service (TOS) 5 to providers other than those enrolled as full-service genetic providers. Reimbursement to those providers is limited to the diagnoses of leukemia and lymphoma.

Refer to: “Cytogenetics Testing for Leukemia and Lymphoma” on page 36-72 for more information.

23.3.4 Genetic Benefit Schedule

23.3.4.1 Genetic Evaluation and Counseling

23.3.4.2 Genetic Diagnostic and Laboratory Procedures

ServiceProcedure Code Limitations

Maximum Fee

Detailed Genetic Health HistoryComprehensive Genetic Physical ExamComplex Psychosocial Genetic Assessment

G-99245 with modifier TG

One per lifetime, per provider

$370.48

Detailed Genetic Health HistoryComplex Genetic Physical ExamStandard Psychosocial Genetic Assessment

G-99244 with modifier TG

One per lifetime, per provider

$248.68

Medical Genetic CounselingInitial Psychosocial Genetic Counseling

G-99215 with modifier TG

One per lifetime, per provider

$147.18

Genetic Health History UpdateStandard Genetic Physical Exam

G-99214 with modifier TG

One per six months, per provider

$81.20

Follow-up Medical Genetic CounselingFollow-up Psychosocial Genetic Counseling

G-99213 with modifier TG

One per six months, per provider

$50.76

Detailed Genetic Health HistoryPrenatal Counseling

G-99404 with modifier TG

One per lifetime, per provider

$152.25

Prenatal Counseling G-99402 with modifier TG

One per pregnancy, per provider*

$50.75

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

Procedure Code Limitation Maximum Fee

G-59000 One per pregnancy, per provider* $70.37

G-59012 One per pregnancy, per provider* $183.30

G-59015 One per pregnancy, per provider* $100.38Genetic Laboratory Procedures

G-81099 or G-84999 or G-85999 or G-86849 or G-87999 or G-88199

Manually priced

G-82013 One per lifetime $9.77

G-82016 Two per provider, per lifetime $18.38

G-82017 Two per provider, per lifetime $13.78

G-82105 One per pregnancy, per provider* $23.18

G-82106 One per pregnancy, per provider* $23.18

G-82127 No limit $18.38

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

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G-82136 No limit $13.78

G-82139 No limit $13.78

G-82261 No limit $13.78

G-82379 No limit $13.78

G-82492 No limit $24.96

G-82541 No limit $24.96

G-82542 No limit $24.96

G-82543 No limit $24.96

G-82544 No limit $24.96

G-82657 Two per provider, per lifetime $24.96

G-82677 One per pregnancy, per provider* $33.43

G-82726 Two per provider, per lifetime $24.96

G-83020 One per lifetime, per provider $17.80

G-83026 One per lifetime $3.26

G-83030 One per lifetime $11.43

G-83033 One per lifetime $8.24

G-83036 One per lifetime $13.42

G-83788 No limit $24.96

G-83789 No limit $24.96

G-83919 No limit $22.75

G-84376 Two per provider, per lifetime $6.43

G-84377 Two per provider, per lifetime $6.43

G-84378 Two per provider, per lifetime $3.98

G-84379 Two per provider, per lifetime $3.98

G-84437 $8.95

G-84450 $7.14

G-84460 $7.32

G-84479 One per lifetime $8.95

G-84550 One per lifetime $6.41

G-84702 One per pregnancy, per provider* $12.07

G-85018 One per lifetime $3.27

G-88230 One per lifetime, per provider $161.00

G-88233 Skin: one per lifetime, per provider Solid Tissue: one per tumor $194.49

G-88235 One per pregnancy, per provider* $203.50

G-88237 Initial diagnosis: one per lifetime, per provider After: one per treatment cycle

$174.55

G-88239 One per lifetime, per tissue type $203.88

G-88240 One per pregnancy or per lifetime if not pregnant $11.74

G-88241 One per pregnancy $11.74

G-88245 One per lifetime, per provider $205.72

G-88248 One per lifetime, per provider $239.32

G-88249 One per pregnancy or per lifetime if not pregnant $239.32

Procedure Code Limitation Maximum Fee

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

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23.3.4.3 Genetic DNA Testing and Laboratory Enzyme TestsEffective for dates of service on or after October 16, 2003, DNA testing and laboratory enzyme tests must be billed with procedure code 84999. To ensure appropriate claims processing, the remarks code reflecting the specific service is also required.

Providers should adhere to the following steps for electronic claim submissions so that TMHP can accurately apply the correct remarks code to the appropriate claim detail:

• A GPC prefix must be submitted in the first three bytes of the NTE02 at the 2400 loop. The GPC prefix should only be submitted once.

• In bytes 4-8, submit the remarks code based on the order of the claim detail (see the following examples).

Example 1: For a claim with three details, where details one and three are submitted with procedure code 84999 and detail two is not submitted with procedure code 84999, enter the following information in the NTE02 at the 2400 loop: GPC4841Z 4964Z, leaving a space between remarks codes for details one and three.

Example 2: For a claim with three details, where details two and three are submitted with procedure code 84999 and detail one is not submitted with procedure code 84999, enter the following information in the NTE02 at the 2400 loop: GPC 4841Z4964Z, leaving a space between the GPC prefix and the remarks code for detail two, and no space between the remarks code for details two and three.

Example 3: For a claim with three details, where all three details are submitted with procedure code 84999, enter the following information in the NTE02 at the 2400 loop: GPC4941Z4861ZY8158, with no spaces between remarks codes.

For paper claim submissions, enter the remarks code in Block 19 of the CMS-1500 claim form.

G-88261 One per lifetime, per provider $244.24

G-88262 Only one (G-88262 or G-88263) per lifetime, per provider $172.25

G-88263 One per lifetime, per provider $207.67

G-88264 One per lifetime, per provider; one per pregnancy $172.25

G-88267 One per pregnancy, per provider* $212.17

G-88269 One per pregnancy, per provider* $229.85

G-88271 $29.60

G-88272 One per lifetime, per provider; one per pregnancy $37.00

G-88273 One per lifetime, per provider $44.40

G-88274 One per lifetime, per provider $48.10

G-88275 One per lifetime, per provider; one per pregnancy $55.50

G-88280 One per lifetime, per provider; one per pregnancy, per provider*

$34.68

G-88283 One per lifetime, per provider; one per pregnancy, per provider*

$94.79

G-88285 One per lifetime, per provider; one per pregnancy, per provider*

$26.26

G-88289 One per lifetime, per provider; one per pregnancy, per provider*

$47.58

G-88291 $5.54

G-88299 One per lifetime, per provider Manually priced

Procedure Code Limitation Maximum Fee

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

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The following tables identify the appropriate remarks codes to use when billing procedure code 84999:

DNA TestingThe following table identifies exceptions when additional services are allowed:

Fetal DNA TestingThe following table identifies exceptions when additional services are allowed:

Remarks Code Laboratory Test Provided Limitations Maximum Fee

4838Z Cystic fibrosis One per lifetime, per provider* $152.25

4839Z Duchenne muscular dystrophy One per lifetime, per provider* $304.50

4840Z Fragile X mental retardation One per lifetime, per provider* $253.75

4841Z Myotonic dystrophy One per lifetime, per provider* $253.75

4842Z Sickle cell hemoglobinopathy One per lifetime, per provider* $253.75

4843Z Ornithine transcarbamoylase deficiency

One per lifetime, per provider* $355.25

4844Z Phenylketonuria One per lifetime, per provider* $355.25

4845Z Thalassemia (alpha) One per lifetime, per provider* $355.25

4846Z Thalassemia (beta) One per lifetime, per provider* $355.25

4847Z Factor VIII deficiency One per lifetime, per provider* $304.50

4848Z Factor IX deficiency One per lifetime, per provider* $304.50

4849Z 21-hydroxylase deficiency One per lifetime, per provider* $304.50

4850Z Lesch Nyhan syndrome (HPRT deficiency)

One per lifetime, per provider* $355.25

4851Z Other miscellaneous DNA testing One per lifetime, per provider * Manually priced

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

Remarks Code Laboratory Test Provided Limitations

Maximum Fee

4852Z Cystic fibrosis One per pregnancy, per provider* $152.25

4853Z Duchenne muscular dystrophy One per pregnancy, per provider* $304.50

4854Z Fragile X mental retardation One per pregnancy, per provider* $253.75

4855Z Myotonic dystrophy One per pregnancy, per provider* $253.75

4856Z Sickle cell hemoglobinopathy One per pregnancy, per provider* $253.75

4857Z Ornithine transcarbamoylase deficiency

One per pregnancy, per provider* $355.25

4858Z Phenylketonuria One per pregnancy, per provider* $355.25

4859Z Thalassemia (alpha) One per pregnancy, per provider* $355.25

4860Z Thalassemia (beta) One per pregnancy, per provider* $355.25

4861Z Factor VIII deficiency One per pregnancy, per provider* $304.50

4862Z Factor IX deficiency One per pregnancy, per provider* $304.50

4863Z 21-hydroxylase deficiency One per pregnancy, per provider* $304.50

4864Z Lesch Nyhan syndrome (HPRT deficiency)

One per pregnancy, per provider* $355.25

4865Z Other miscellaneous DNA Testing One per pregnancy, per provider* Manually priced

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

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Section 23

Biochemical TestsIf TMHP denies the HCPCS code billed as not a benefit or exceeds the program benefits, providers may appeal with documentation of medical necessity.

Remarks Code

Laboratory Test Provided

Type of Specimen Limitations

Maximum Fee

Y8150 Alpha-N acetylglucosaminidase

F Two per provider per lifetime of client per specimen

$73.83

Y8151 AF One per pregnancy per provider $73.83

Y8152 Acid lipase WBC Two per provider per lifetime of client per specimen

$41.09

Y8153 F Two per provider per lifetime of client per specimen

$83.74

Y8154 AF One per pregnancy per provider $83.74

Y8155 Acid phosphatase WBC Two per provider per lifetime of client per specimen

$41.09

Y8156 F Two per provider per lifetime of client per specimen

$83.74

Y8157 AF One per pregnancy per provider $83.74

Y8158 Adenosine deaminase RBC Two per provider per lifetime of client per specimen

$41.09

Y8159 F Two per provider per lifetime of client per specimen

$83.74

Y8160 AF One per pregnancy per provider $83.74

Y8161 Aldolase WBC Two per provider per lifetime of client per specimen

$41.09

Y8162 F Two per provider per lifetime of client per specimen

$83.74

Y8163 AF One per pregnancy per provider $83.74

Y8164 Arginase RBC Two per provider per lifetime of client per specimen

$41.09

Y8165 Argininosuccinic acid synthetase

Liver Two per provider per lifetime of client per specimen

$35.53

Y8166 Amino acid qualitative screen

U Two per provider per lifetime of client per specimen

$8.13

Y8167 P Two per provider per lifetime of client per specimen

$8.13

Y8168 Amino acid quantitative screen

U Two per provider per lifetime of client per specimen

$128.91

Y8169 S Two per provider per lifetime of client per specimen

$128.91

Y8170 Aryl sulfatase A WBC Two per provider per lifetime of client per specimen

$41.09

Y8171 F Two per provider per lifetime of client per specimen

$83.74

Y8172 AF One per pregnancy per provider $83.74

Y8173 Aryl sulfatase B WBC Two per provider per lifetime of client per specimen

$41.09

Y8174 F Two per provider per lifetime of client per specimen

$83.74

Y8175 AF One per pregnancy per provider $83.74

Legend for Type of Specimen: F=Fibroblast WB=Whole Blood S=Serum P=Plasma U=Urine T=Tissue WBC=White Blood Cells B=Skin Biopsy AF=Amniotic Fluid RBC=Red Blood Cells

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Y8176 Beta-aspartylglu-cosaminidase

SB Two per provider per lifetime of client per specimen

$35.53

Y8177 Cholinesterase-pseudo S Two per provider per lifetime of client per specimen

$19.26

Y8178 Cholinesterase-true WB Two per provider per lifetime of client per specimen

$23.11

Y8179 Cystathionase WB Two per provider per lifetime of client per specimen

$103.37

Y8180 WBC Two per provider per lifetime of client per specimen

$105.38

Y8181 Cystathionine synthase SB Two per provider per lifetime of client per specimen

$105.94

Y8182 Enzyme screen P Two per provider per lifetime of client per specimen

$186.18

Y8183 Erythrocyte galactokinase

Any Two per provider per lifetime of client per specimen

$128.40

Y8186 Alpha-L-fucosidase WBC Two per provider per lifetime of client per specimen

$41.09

Y8187 F Two per provider per lifetime of client per specimen

$83.74

Y8188 AF One per pregnancy per provider $83.74

Y8189 Beta-galactocerebrosidase

WBC Two per provider per lifetime of client per specimen

$35.53

Y8190 S Two per provider per lifetime of client per specimen

$20.30

Y8191 SB Two per provider per lifetime of client per specimen

Manually priced

Y8192 P Two per provider per lifetime of client per specimen

Manually priced

Y8193 Galactose transferase WB Two per provider per lifetime of client per specimen

$32.74

Y8194 Alpha-galactosidase WBC Two per provider per lifetime of client per specimen

$41.09

Y8195 F Two per provider per lifetime of client per specimen

$83.74

Y8196 AF One per pregnancy per provider $83.74

Y8197 Beta-galactosidase WBC Two per provider per lifetime of client per specimen

$41.09

Y8198 F Two per provider per lifetime of client per specimen

$83.74

Y8199 AF One per pregnancy per provider $83.74

Y8200 Glucose-6 phosphate dehydrogenase

WB Two per provider per lifetime of client per specimen

$25.28

Remarks Code

Laboratory Test Provided

Type of Specimen Limitations

Maximum Fee

Legend for Type of Specimen: F=Fibroblast WB=Whole Blood S=Serum P=Plasma U=Urine T=Tissue WBC=White Blood Cells B=Skin Biopsy AF=Amniotic Fluid RBC=Red Blood Cells

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Y8201 Alpha-glucosidase WBC Two per provider per lifetime of client per specimen

$41.09

Y8202 F Two per provider per lifetime of client per specimen

$83.74

Y8203 AF One per pregnancy per provider $83.74

Y8204 Beta-glucosidase WBC Two per provider per lifetime of client per specimen

$41.09

Y8205 F Two per provider per lifetime of client per specimen

$83.74

Y8206 AF One per pregnancy per provider $83.74

Y8207 Beta-glucuronidase S Two per provider per lifetime of client per specimen

$25.68

Y8208 WBC Two per provider per lifetime of client per specimen

$41.09

Y8209 F Two per provider per lifetime of client per specimen

$83.74

Y8210 AF One per pregnancy per provider $83.74

Y8211 Glycogen storage disease enzyme assay series

Any Two per provider per lifetime of client per specimen

$449.39

Y8212 Glycogen debrancher enzyme

Any Two per provider per lifetime of client per specimen

$329.88

Y8213 GM2 type 2 WBC Two per provider per lifetime of client per specimen

$19.90

Y8214 SB Two per provider per lifetime of client per specimen

$105.94

Y8215 Heparin sulfate N-sulfamidase

F Two per provider per lifetime of client per specimen

$83.74

Y8216 AF One per pregnancy per provider $83.74

Y8217 Hexosaminidase A S Two per provider per lifetime of client per specimen

$20.30

Y8218 WBC Two per provider per lifetime of client per specimen

$126.88

Y8219 SB Two per provider per lifetime of client per specimen

$36.54

Y8220 Hexosaminidase A and B

S Two per provider per lifetime of client per specimen

$25.68

Y8221 WBC Two per provider per lifetime of client per specimen

$41.09

Y8222 F Two per provider per lifetime of client per specimen

$83.74

Y8223 AF One per pregnancy per provider $83.74

Y8224 Hypoxanthine-guanine-phosphoribosyl-transferase

RBC Two per provider per lifetime of client per specimen

$38.52

Y8225 F Two per provider per lifetime of client per specimen

$83.74

Y8226 AF One per pregnancy per provider $83.74

Remarks Code

Laboratory Test Provided

Type of Specimen Limitations

Maximum Fee

Legend for Type of Specimen: F=Fibroblast WB=Whole Blood S=Serum P=Plasma U=Urine T=Tissue WBC=White Blood Cells B=Skin Biopsy AF=Amniotic Fluid RBC=Red Blood Cells

Genetic Services

23

Y8227 Alpha-L-iduronidase (Hurler and Scheie’s S)

WBC Two per provider per lifetime of client per specimen

$83.74

Y8228 F Two per provider per lifetime of client per specimen

$83.74

Y8229 AF One per pregnancy per provider $83.74

Y8230 Alpha-L-iduronidase sulfatase (Hunter's S)

S Two per provider per lifetime of client per specimen

$68.06

Y8231 Alpha-mannosidase WBC Two per provider per lifetime of client per specimen

$32.10

Y8232 F Two per provider per lifetime of client per specimen

$83.74

Y8233 AF One per pregnancy per provider $83.74

Y8234 Mucolipidosis II (1-cell disease)

WBC Two per provider per lifetime of client per specimen

$21.83

Y8235 Mucolipidosis II (beta-galactosidase)

SB Two per provider per lifetime of client per specimen

$105.94

Y8236 Mucolipidosis III (pseudo-Hurler)

SB Two per provider per lifetime of client per specimen

$93.10

Y8237 Neuraminidase WB Two per provider per lifetime of client per specimen

$68.70

Y8238 Nucleoside phosphorylase

RBC Two per provider per lifetime of client per specimen

$38.52

Y8239 F Two per provider per lifetime of client per specimen

$83.74

Y8240 AF One per pregnancy per provider $83.74

Y8241 Organic acid screen U Two per provider per lifetime of client per specimen

$126.88

Y8242 Ornithine transcarbamoylase

Liver Two per provider per lifetime of client per specimen

$24.29

Y8243 Orotate phosphoribosyl transferase

Any Two per provider per lifetime of client per specimen

Manually priced

Y8244 Orotidylic-decarboxylase Any Two per provider per lifetime of client per specimen

Manually priced

Y8245 Feroxidase WB Two per provider per lifetime of client per specimen

$64.20

Y8246 Phenylalanine S Two per provider per lifetime of client per specimen

$12.84

Y8247 Phosphorylase-B-kinase Any Two per provider per lifetime of client per specimen

$329.88

Y8248 PP-ribose-P aminotransferase

Any Two per provider per lifetime of client per specimen

Manually priced

Y8249 PP-ribose-P synthetase Any Two per provider per lifetime of client per specimen

Manually priced

Y8250 Pyruvate kinase WB Two per provider per lifetime of client per specimen

$23.11

Remarks Code

Laboratory Test Provided

Type of Specimen Limitations

Maximum Fee

Legend for Type of Specimen: F=Fibroblast WB=Whole Blood S=Serum P=Plasma U=Urine T=Tissue WBC=White Blood Cells B=Skin Biopsy AF=Amniotic Fluid RBC=Red Blood Cells

23–11

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Section 23

23.3.4.4 Genetic Ultrasound Testing Procedures

General Genetic Services LimitationsWhen multiple ultrasound procedure codes are billed on the same day, the most inclusive code will be paid and all other codes will be denied.

Y8251 Sphingomyelinase WBC Two per provider per lifetime of client per specimen

$41.09

Y8252 F Two per provider per lifetime of client per specimen

$83.74

Y8253 AF One per pregnancy per provider $83.74

Y8254 UDPG transferase RBC Two per provider per lifetime of client per specimen

$38.52

Y8255 F Two per provider per lifetime of client per specimen

$83.74

Y8256 AF One per pregnancy per provider $83.74

Y8257 Urine mucopolysaccha-rides screen (thin-layer chromatography)

U Two per provider per lifetime of client per specimen

$38.52

Y8258 Urine mucopolysaccha-rides screen (quantitative study)

U Two per provider per lifetime of client per specimen

$148.94

Y8259 Xanthine oxidase Any Two per provider per lifetime of client per specimen

Manually priced

Y8260 Lactate/pyruvate kinase S Two per provider per lifetime of client per specimen

$38.06

Y8261 Lactate/pyruvate tolerance tests

T Two per provider per lifetime of client per specimen

$203.00

Procedure Code Limitations Maximum Fee

G-76805 One per pregnancy, per provider* $104.19

G-76810 One per pregnancy, per provider* $207.57

G-76811 $177.63

G-76811 with modifier TS $97.44

G-76812 $177.63

G-76812 with modifier TS $97.44

G-76815 One per pregnancy, per provider* $69.56

G-76816 One per pregnancy, per provider* $57.28

G-76818 One per pregnancy, per provider* $80.47

G-76819 One per pregnancy, per provider* $70.37

G-76825 One per pregnancy, per provider* $90.01

G-76826 One per pregnancy, per provider* $61.92

G-76827 One per pregnancy, per provider* $83.46

G-76941 One per pregnancy, per provider* $98.19

G-76945 One per pregnancy, per provider* $79.92

G-76946 One per pregnancy, per provider* $60.55

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies the claim.

Remarks Code

Laboratory Test Provided

Type of Specimen Limitations

Maximum Fee

Legend for Type of Specimen: F=Fibroblast WB=Whole Blood S=Serum P=Plasma U=Urine T=Tissue WBC=White Blood Cells B=Skin Biopsy AF=Amniotic Fluid RBC=Red Blood Cells

Genetic Services

3

Reimbursement for genetic ultrasound services will be made for the total component (TOS G) only. Professional (TOS I) and technical (TOS T) components are considered a part of the total service.

Reimbursement for referred genetic services will only be made upon proof of formal referral of a client to the consultant by the genetics provider.

Independent consultant, laboratory, counseling, and radiological genetic services:

• Must be billed through the genetic provider under contract with DSHS

• Related to the genetic workup of a client is not a covered benefit

A fetal biophysical profile (G-76818 and G-76819) and an echography (G-76805 through G-76816) may be billed on the same day for the same client.

23.4 Claims InformationGenetic services must be submitted to TMHP in an approved electronic format or on a CMS-1500 claim form. Providers must purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply them.

TMHP representatives are available for provider questions about genetic services, such as reimbursement rates and procedures. For more information call the TMHP Contact Center at 1-800-925-9126.

23.4.1 Claim Filing ResourcesRefer to the following sections and/or forms when filing claims:

ResourcePage Number

Automated Inquiry System (AIS) xi

TMHP Electronic Data Interchange (EDI) 3-1

CMS-1500 Claim Filing Instructions 5-18

TMHP Electronic Claims Submission with the TMHP

5-11

Communication Guide A-1

Genetics D-15

Acronym Dictionary F-1

2

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