Medicare coverage of genetic counseling services

(a)

In general

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—(1)in subsection (s)(2)—(A)by striking and at the end of subparagraph (GG);(B)by adding and at the end of subparagraph (HH); and(C)by adding at the end the following new subparagraph:

(II)covered genetic counseling services (as defined in subsection (kkk)(1));

; and

(2)by adding at the end the following new subsection:

(kkk)

Covered Genetic Counseling Services

(1)The term ‘covered genetic counseling services’ means genetic counseling services furnished by a genetic counselor (as defined in paragraph (2)) (and such services and supplies furnished as an incident to the provision of such services) as would otherwise be covered under this title if furnished by a physician (or as incident to a physician’s service).(2)The term genetic counselor means an individual who—(A)is licensed as a genetic counselor by the State in which the individual furnishes genetic counseling services; or(B)in the case of an individual practicing in a State that does not license genetic counselors, meets such other criteria as the Secretary establishes.

The provisions of this paragraph shall not be construed as preventing other practitioners, including those providing telehealth services, from providing covered genetic counseling services within the scope of their practice.

(b)

Physicians’ services

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(II), after ‘‘(2)(FF) (including administration of the health risk assessment),’’.(c)

Payment

(1)

In general

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—(A)by striking and (CC) and inserting (CC); and(B)by inserting before the semicolon at the end the following: ‘‘, and (DD) with respect to covered genetic counseling services under section 1861(s)(2)(II), furnished by a genetic counselor, the amount of payment for such service shall be an amount equal to 85 percent of the lesser of the actual charge for the services or the amount determined under the fee schedule established under section 1848(b) for the same services if furnished by a physician’’.(2)

Modifier

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(x)

Use of modifier with respect to genetic counseling services

(1)

Establishment

Not later than January 1, 2022, the Secretary shall establish a modifier to be utilized with evaluation and management CPT codes to indicate (in a form and manner specified by the Secretary), in the case of covered genetic counseling services under section 1861(s)(2)(II), if such services were furnished by a genetic counselor.(2)

Required use

Each request for payment, or bill submitted using evaluation and management CPT codes, for covered genetic counseling services (as defined in section 1861(kkk)(1)) furnished by a genetic counselor (as defined in section 1861(kkk)(2)) on or after January 1, 2022, shall include the modifier established under subparagraph (A) for each such service.

(d)

Assignment of payment

Section 1833(r) of the Social Security Act (42 U.S.C. 1395l(r)) is amended by adding at the end the following new paragraph:

(3)

Application to genetic counselors

The provisions of paragraphs (1) and (2) shall apply with respect to covered genetic counseling services described in section 1861(s)(2)(II) and genetic counselors (as defined in section 1861(kkk)(2)) in the same manner as such provisions apply with respect to services described in section 1861(s)(2)(K)(ii) and nurse practitioners.

(e)

Conforming amendment

Section 1862(a)(14) of the Social Security Act (42 U.S.C. 1395(y)(a)(14)) is amended by inserting ‘‘covered genetic counseling services,’’ after ‘‘qualified psychologist services,’’.(f)

Effective date

(1)

In general

The amendments made by this section shall apply to services furnished on or after January 1, 2022.(2)

Implementation

The Secretary of Health and Human Services may implement the amendments made by this section by interim final rule with comment period.