Oncology & Hematology Coding Alert

Pay attention to who provided the services.

You may face denials for genetic counseling services if you do not pay attention to when and to what extent you can report these services. With the increase in understanding of disease and diagnosis, genetic counseling is becoming a common service. You will need to acquaint yourself with skills report genetic counseling services.  

Who is a genetic counselor? A genetic counselor is a healthcare professional who has received specialized education and training to interpret family history information educate and provide support and guidance to individuals or families who are predisposed to a genetic disorder. “Genetic counselors can also help patients prepare and address the psychosocial and ethical issues associated with the specific disorder,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. “They would also help the patient understand their options, discuss how to reduce their risk of contracting the illness (if possible) and refine risk by obtaining additional information through the use of genetic tests.” Currently, the American Board of Genetic Counselors (ABMG) certifies genetic counselors in the US and Canada.

You should report 96040 (Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family) only for services that a trained genetic counselor provides. 

Here are five questions that can strengthen your understanding of genetic counseling services.

1. Can a physician be a genetic counselor? Your physician can provide genetic counseling, but it is best to have dedicated and trained personnel for genetic counseling. You cannot use 96040 for genetic counseling by a physician or nonphysician healthcare worker who is not a genetic counselor.

2. How can you report the genetic counseling services of your physician? Although nothing precludes a physician from also being a genetic counselor, CPT® states that if a physician provides genetic counseling to an individual, choose the appropriate E/M code. When the physician counsels a patient without symptoms or an established disease, CPT® points you instead to 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) - 99402 (…approximately 30 minutes).

3. What services are inclusive in 96040? According to CPT®, before reporting 96040, you also should watch for the following services: 

• Obtaining a structured family genetic history;

• Construction of a pedigree chart;

• Analysis for genetic risk assessment; and 

• Counseling of the patient and family.

4. How many units of 96040 can you report? The counselor may provide genetic counseling services during one or more sessions and may review medical data and family information, conduct face-to-face interviews, and provide advice. You report 1 unit of code 96040 for at least 16 minutes to 30 minutes of documented service. For example, if counseling time was documented as lasting 50 minutes, you would report two (2) units of 96040. “The first unit would be for the first 30 minutes. The second unit would be for the last 20 minutes of the service,” Loya says.

5. How do we report if a patient receives genetic counseling but has no symptoms? If the patient receiving genetic counseling lacks symptoms, you should consider a V code for ICD-9-CM and a Z code for ICD-10-CM. There are specific V or Z codes for patients who have been tested and have a genetic probability. These codes are listed in table 1.