TMPPM 2008 >22.3.1.1 Genetic Evaluation and Counseling

Only a full-service genetic services provider enrolled in the Texas Medicaid Program as a geneticist may bill the following evaluation and management codes under type of service G.


Procedure Code	Limitations	Maximum Fee
G-96040	None	$26.73
G-99213	None	$50.76
G-99214	None	$81.20
G-99215	One per year, any provider	$147.18
G-99244	One every three years, any provider	$248.68
G-99245	One every three years, any provider	$370.48
G-99254	One every three years, any provider	$248.68
G-99255	One every three years, any provider	$370.48
G-99402	One per pregnancy, per provider*	$50.75
G-99404	One every three years, any provider	$152.25
* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies a claim.

One office consultation (procedure codes G-99244 or G-99245) may be considered for reimbursement if procedure codes G-99244, G-99245, G-99254, and/or G-99255 have not been submitted and reimbursed in the previous three years.

Inpatient consultations (procedure codes G-99254 and G-99255) may be considered for reimbursement once every three years even if an office consultation has been reimbursed in the previous three years.

In addition to meeting the requirements for the specific physician evaluation and management procedure code, the enrolled geneticist must also provide the following services in the components listed below for consideration of enhanced reimbursement. Documentation in the medical record must support the level of code submitted.

The comprehensive history, as part of genetic services, should include an extensive medical and family history covering at least three matriarchal and patriarchal generations. A pedigree is constructed. This history includes any affected individuals in the immediate or extended family, information on pregnancy, plus a developmental, educational, and social history.

The family genetic health history update 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.

The focus of the comprehensive examination related to genetic services may vary according to specific client needs. The comprehensive examination typically includes, but is not limited to, extensive anthropomorphic measurements, such as 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 as well as a complete physical examination.

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

Counseling includes prognosis, recurrence risks, family planning implications, and the options available to family members who are at increased risk for giving birth to individuals with the same condition. A counseling procedure code should be submitted if counseling is the only service provided.