CSHCN Services Program 2010 > Physician > Benefits, Limitations, and Authorization Requirements

30.2.21 Genetics

Geneticists provide services to evaluate clients for the possibility of a genetic disorder, diagnose such disorders, counsel clients and families regarding such disorders, and provide follow-up care to clients with known or suspected disorders.

Genetic services provided by geneticists are benefits of the CSHCN Services Program, and include the professional component (consultative counseling and follow-up). Laboratory services relating to genetic services are covered separately.

The following procedure codes may be reimbursed for geneticists when provided in the office, inpatient hospital, or outpatient hospital setting:

Consultation, procedure codes 99244, 99245, and 99404, are limited to once every 3 years. One office consultation (procedure codes 99244 or 99245) may be reimbursed if an office/outpatient/inpatient consultation has not been reimbursed in the previous 3 years.

Inpatient consultations (procedure codes 99254 and 99255) may be reimbursed once every 3 years regardless of whether an office consultation was reimbursed in the previous 3 years.

A comprehensive follow up visit (procedure code 99215) is limited to once per year.

No authorization is required for genetic services that are a benefit of the CSHCN Services Program.

Refer to: Section 24.2.5.1, "Cytogenetics Testing" for more information on cytogenetic testing.