24-588 Expanded Prenatal Screening Program
Date: 06/14/24
Follow the process and billing guidelines outlined below
Effective April 1, 2024, the California Department of Health (CDPH) Prenatal Screening Program issued a letter1 (PDF) adding sex chromosome aneuploidy (X, XXY, XYY, XXX) screening to its cell-free DNA (cfDNA) prenatal screening panel. This is in addition to the already available fetal autosomal trisomies (trisomy 21, trisomy 18, and trisomy 13) offered in the first and second trimesters of pregnancy.
Physicians and other providers must use the correct diagnosis code, correct testing codes and a California Prenatal Screening (PNS) Program-contracted lab for prenatal genetic screening to be covered under the PNS program.
Billing guidelines
Refer to the appropriate codes when billing for PNS.
Medi-Cal
The billing process for Medi-Cal remains unchanged. The PNS program is being expanded to include sex chromosome screening as stated above.
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Code | description |
|---|---|
CPT Code: 81420 | Fetal chromosomal aneuploidy (trisomy 13, 18 and 21), including sex chromosome aneuploidy (X, XXY, XYY, XXX) screening |
PLA Code: 0327U | Fetal aneuploidy (trisomy 13, 18 and 21) |
CPT Code: 82105 | Alpha-fetoprotein, maternal serum |
Diagnosis code: Z360 (no decimal or additional digits) | Encounter for antenatal screening of mother |
Commercial
When the Division of Financial Responsibility (DOFR) indicates Health Net holds risk, Health Net will also reimburse in-network providers other than the California PNS Program for these codes, but Health Net strongly encourages providers to use the California PNS Program due to its advantages for providers and members, including:
- Consolidated genetic screening (blood tests), genetic counseling, and confirmatory, in-person, invasive diagnostic testing (e.g., chorionic villus sampling).
- No prior authorization—prior authorization is not required when referring patients to the PNS Program.
- No copay—physicians and other providers must use the PNS Program in order for members on Commercial plans to have no copay for certain services and supplies (e.g., initial testing, subsequent testing and certain follow-up services through PNS Program-contracted providers).
For Commercial and Marketplace, providers can send specimens to any contracted lab.
Referrals to PNS Program-contracted labs and ordering supplies for blood draws
The PNS Program referral form is available on the PNS Program website and must be used with members referred to a PNS Program-contracted lab for services to be covered under the PNS Program.
To order blood draw supplies and other supplies for members on Commercial plans or Medi-Cal, physicians and other providers must use forms available via the PNS Program website > Information for Providers > Ordering Supplies > Clinician Offices and Hospitals Supplies Ordering.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal.
1https://www.cdph.ca.gov/Programs/CFH/DGDS/CDPH%20Document%20Library/PNS%20Documents/Prenatal_Insurer_Letter_2024.pdf
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, including Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.