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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.14 BRCA Testing

8.2.14
Gene mutation analyses are benefits of Texas Medicaid for clients who are 18 years of age and older when billed with the following procedure codes: S3820, S3822, S3823, 81211, 81212, 81214, 81215, 81216, and 81217.
Breast cancer type 1, early onset (BRCA1) and breast cancer type 2, susceptibility protein (BRCA2) are tumor repressor genes responsible for keeping breast cells from growing too rapidly or in an uncontrolled way. Mutations within the gene interrupt this regulatory function and increase the risk of breast cancer.
Note:
Interpretation of gene mutation analysis results is not separately reimbursable. Interpretation is part of the physician E/M service.
The following procedure codes, which describe the three basic steps for testing for a BRCA mutation, are not considered for reimbursement when submitted with a breast cancer diagnosis code (1740, 1741, 1742, 1743, 1744, 1745, 1746, 1748, 1749, 1750, 1759, 1982, 19881, and 2330):
B‑hexasominidase (procedure code 83080)
Claims filed using these procedure codes with a diagnosis of breast cancer may be reviewed on appeal.
BRCA1 and BRCA2 analyses (procedure codes S3820, S3822, S3823, 81211, 81212, 81214, 81215, 81216, and 81217) are limited to once per lifetime. Additional services may be considered on appeal.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.