New Covered CPT Codes for Genetic Testing

Effective June 1, 2024, CPT codes are newly eligible for coverage.

Effective June 1, 2024, the CPT codes in the table below are newly eligible for coverage.      The Genetic Testing clinical coverage policies are in the process of being updated to reflect this guidance. Refer to the North Carolina Medicaid Fee Schedule download site for rates related to these codes.

Existing coverage will not be revoked; rather, it will be reorganized within the framework of the new policy structure. Please consult the relevant clinical coverage policy upon its final posting for detailed information regarding this reorganization. A bulletin will be posted announcing the final posting of these policies with their new clinical coverage policy numbers.    

New Coverage Category

Summary Updates

New Covered CPT Codes Effective 6/1/2024
Diagnosis & Treatment
  • New coverage criteria being added for Lynch syndrome, cancer susceptibility, Duchenne Muscular Dystrophy (DMD) and Becker Muscular Dystrophy (BMD), and red blood cell (RBC) genotyping.
  • New CPT codes being added to coverage that fall under general criteria in Section 3.2.1(a).
 0001U, 0022U, 0101U, 0102U, 0103U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0138U, 0162U, 0172U, 0230U, 0234U, 0238U, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81163, 81164, 81165, 81166, 81171, 81172, 81173, 81174, 81175, 81176, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81206, 81207, 81208, 81210, 81216, 81218, 81219, 81233, 81235, 81236, 81237, 81242, 81245, 81246, 81251, 81255, 81257, 81258, 81259, 81269, 81270, 81271, 81272, 81274, 81279, 81287, 81288, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81307, 81308, 81309, 81310, 81311, 81315, 81316, 81317, 81318, 81319, 81320, 81332, 81334, 81338, 81339, 81345, 81347, 81348, 81351, 81352, 81353, 81357, 81360, 81361, 81362, 81363, 81364, 81412, 81432, 81433, 81435, 81436, 81437, 81438, 81441
Carrier & Prenatal
  • Additional CPT codes being added to the coverage, however, no major updates here.
  • Maintaining the criteria that prenatal testing is covered for all pregnant beneficiaries, regardless of maternal age and baseline risk.
  • Maintaining the criteria that carrier testing is available to beneficiaries who are pregnant OR considering pregnancy.
 0209U, 81161, 81255, 81257, 81258, 81259, 81269, 81271, 81274, 81349, 81361, 81362, 81363, 81364, 81412, 81422, 81508, 81509, 81510, 81511, 81512, 88249
Gene Expression
  • Maintaining coverage for breast cancer and adding coverage for thyroid cancer.
 0018U, 0026U, 0204U, 0245U, 0287U, 81518, 81520, 81521, 81523, 81546
Next Generation Sequencing (NGS)
  • New coverage for Whole Genome Sequencing (12 months and younger, either admitted or recently discharged from NICU or PICU).
  • New coverage for molecular profiling, including liquid biopsy.
  • For Whole Exome Sequencing and Whole Genome Sequencing, when specific criteria are met, NC Medicaid is including coverage of the;
    • initial test
    • comparator testing
    • reanalysis  
 81416, 81417, 81425, 81426, 81427, 0037U, 0048U, 0094U, 0211U, 0212U, 0213U, 0242U, 0244U, 0250U, 0326U, 0329U, 0334U, 0379U, 0391U, 81457, 81458, 81459, 81462, 81463, 81464, 0364U, 0379U, 0388U, 0391U, 0395U, 0409U, 0417U


Contact

NCTracks Call Center: 800-688-6696   
NC Medicaid Managed Care health plans 
 

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