Genetic Counseling and Testing

Genetic counseling is a covered benefit when billed as an Evaluation and Management (E&M) code. Medical genetics and genetic counseling billed with CPT® 96040 are not covered under the TRICARE program.

Genetic testing is a limited benefit. Tests approved by the U.S. Food and Drug Administration (FDA) are covered to confirm a clinical diagnosis that is already suspected based on the patient's symptoms and when the results of the test will influence  management or treatment. Learn more about coverage for genetic testing by visiting our Laboratory Developed Tests page for details.

Cost Information

• Chromosome analysis (to include karyotyping and/or high resolution chromosome analysis) in some cases of habitual abortion or infertility
• Testing for Marfan Syndrome and chromosome analysis (to include karyotyping and/or high resolution chromosome analysis) of children (Common indications for chromosome analysis in children to include ambiguity of external genitalia, small-for-gestational age infants, multiple anomalies, and failure to thrive.)
• Preconception and prenatal carrier screening for the following conditions:
  • Cystic fibrosis
  • Spinal muscular atrophy
  • Fragile X syndrome
  • Tay-Sachs disease
  • Hemoglobinopathies
  • Conditions linked with Ashkenazi Jewish descent
• Other medically necessary genetic diagnostic tests

Pre-authorization is required for most genetic testing except cystic fibrosis. For preconception and prenatal screening, we have a letter of attestation you can attach to the request in lieu of clinical documentation.

TRICARE excludes routine genetic testing that does not influence the beneficiary’s medical management (for example, the Agendia® Breast Cancer Test Suite [MammaPrint®, TargetPrint® and BluePrint® tests] and the 23andMe Personal Genome Service [PGS] test).

Note: Refer to Laboratory Developed Tests for more information.

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