# Genetic counseling - Our facility is going to start



## lillianivy (Oct 10, 2013)

Our facility is going to start having our Nurse Practitioners do Genetic Counseling.  I need help on how to code and bill for this service.

I know there are 2 time based codes to use:
96040
S0265
I am not certain which one to use.  I know Medicare does not accept S0265.  Does Medicare pay for this service at all?  And what about other insurance companies?  

I know to use the V26.33 as the DX.  

Is a physical required for Genetic Counseling?  

Any advice or websites or articles that can help would be greatly appreciated. 

Thank you,

Lydia


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## Pamski (Oct 11, 2013)

*Use of CPT code 96040*

Use the 96040 CPT code.  S0265 code was before the 96040 CPT code in HCPCS. It is out of date.  96040 is in 30 minute increments or units of time.

There are no RVU's for the 96040 CPT code.  Therefore, Medicare/Medicaid does not pay for this code.  However, there are other major commerical insurances that do pay for the 96040 CPT code.

Pam


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## lillianivy (Oct 16, 2013)

*Help!!!*

Well then my question is can we bill genetic counseling as a time based office visit 99211-99215) across the board?  And just use the symptoms or established disease as the dx and make sure the documentation supports, even though the visit is for genetic counseling? Since Medicare/Medicaid does not pay for 96040 or S0265, and some commercial ins. That way we are still getting paid for services rendered.  

Help!!! Just trying to figure out the best way to properly bill for this so our Nurse Practitioners get paid for their time. 

Thanks,
Lydia


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## DCarmelaMD (Feb 21, 2016)

*96040 how many time provider can bill*

kindly let me know if the counseling done 90 minutes can the provider billed 96040 cpt code 3 times ?


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## Pam Brooks (May 13, 2016)

96040 is a code to be used only for non-physician practitioners.  Since here in NH, APRNs can bill with their own Medicare number, we consider them physicians, and we bill only an E&M code for their providing Genetic Counseling.  The 96040 is pretty much for a genetic counselor (master's level clinician, with no ability for a Medicare provider status).  So you would be correct to bill consistently an E&M (based on counseling time).


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## pjw32460 (Nov 12, 2020)

DCarmelaMD said:


> *96040 how many time provider can bill*
> 
> kindly let me know if the counseling done 90 minutes can the provider billed 96040 cpt code 3 times ?


I, also, will like to know this.  I am now coding for a Genetic Counselor and she is charging 96040 and she documents much more time than 30 minutes


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## SharonCollachi (Nov 12, 2020)

The answer is in the definition of the code.

96040 - Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family.

"Each 30 minutes" means you bill in 30 minute increments.

The introduction to that section states, "Code 96040 is reported for each 30-minute increment of face-to-face time. Do not report 96040 for 15 minutes or less of face-to-face time. Report 96040 once for 16 to 30 minutes.

For genetic counseling and education provided to an individual or by a physician or other professional who may report E&M services, see the appropriate E&M codes.  For genetic counseling provided to a patient without symptoms or established disease, by a physician, use 99401-99412.


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## trarut (Nov 12, 2020)

I researched and set up the billing process for the last oncology practice I worked where genetic counseling services were offered.  What I recall is:

  We used E/M codes, not 96040 because it was an NP or MD performing the encounter.  We did not have a licensed genetic counselor on staff to qualify to bill 96040.  We did not use the 994xx codes.
  Diagnosis codes were reported in the following order, as applicable to the individual patient and visit:
cancer code if previously diagnosed;​
personal and/or family histories of cancer;​
genetic counseling Z code;​
encounter for screening/testing Z code if decision to proceed was made at the visit; and​
genetic susceptibility to malignant neoplasm if a positive test result was noted.  Typically reported only for established patients but could be reported for a new patient IF prior testing was done and the results known and documented​

Some patients were seen by one provider for a medical visit and the second provider for the genetic counseling visit and we did use a 25 modifier on the second encounter (after validating both visit notes supported separate services).  These did typically require submission of the medical records to prove the separate visits before the plans would pay for both
Z71.83 is not restricted from being reported as a primary diagnosis in ICD-10 but our experience was that the plans will not allow it as a primary.  Claims were denied for an invalid primary diagnosis when genetic counseling was listed first.  If the patient didn't have cancer, a history of cancer or a family history putting them at risk, the visit would not be necessary so we deemed it ok to report the genetic counseling in a secondary diagnosis spot.

Hope this helps.


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