EST. 1999
Genetic Counseling and Evaluation for BRCA Testing; and BRCA Lab Screening
Service:
USPSTF: United States Preventative Services Task Force
The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal or peritoneal cancer or who have ancestry associated with breast cancer susceptibility 1 and 2 (BRCA 1 / 2 ) gene mutations with appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling, genetic testing.
Refer to the Medical Policy titled
Procedure Code(s):
Medical Genetics and Genetic Counseling Services:
96041, S0265
Evaluation and Management (Office Visits):
99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99417, 99385, 99386, 99387, 99395, 99396, 99397, G0463
Diagnosis Code(s):
Z15.01, Z15.02, Z83.0 Z80.41, Z85.3, Z85.43
BRCA Lab Screening:
81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217
Blood Draw:
36415, 36416
Diagnosis Code(s):
Family History or Personal History of breast cancer and/or ovarian cancer:
Z15.01, Z15.02, Z80.3, Z80.41, Z85.3, Z85.43
Preventive Benefit Instructions:
Genetic Counseling and Evaluation
*Medical Necessity plans require genetic counseling before BRCA Lab Screening.
Requires on of the Genetic Counseling and Evaluation diagnosis codes listed above in the primary position.
BRCA Lab Screening:
*Prior authorization requirements apply to BRCA lab screening.
Applies to age 18+ when billed with one of the BRCA Lab Screening diagnosis codes listed above.
Blood Draw:
Requires one of the BRCA Lab Screening procedure codes listed in this row and one of the BRCA lab screening diagnosis codes listed above.