Oncology & Hematology Coding Alert

Find out whether a physician counts as a genetic counselor.

Suppose a pancreatic cancer patient wants to know whether his cancer can be passed down to his children. Your oncologist orders genetic counseling, and now you’re wondering how to report this.

Genetic counseling claims relies on two aspects: (1) when the counseling took place and (2) what extent you can report these services.

First, Define Who is a Genetic Counselor

A genetic counselor is a healthcare professional who has received specialized education and training to interpret family history information, provide education, support and guidance to individuals or families who are predisposed to a genetic disorder. “Genetic counselors can also help patients prepare for psychosocial and ethical issues associated with the specific disorder,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, North Carolina. “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 which a trained genetic counselor provides.

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

Question 1: Can a Physician be a Genetic Counselor?

Answer 1: 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 professional if qualified to report E/M or preventative counseling codes as applicable to the service rendered. (More about this in #2 below.) Counseling by other allied health individuals who are qualified to perform this service would report this code.

Question 2: How Do I Report My MD’s Genetic Counseling Services?

Answer 2: Although nothing precludes a physician from also being a genetic counselor, CPT^® states 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).

Question 3: What Services Does 96040 Include?

Answer 3: 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.

Question 4: How Many Units of 96040 Can I Report?

Answer 4: 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 one (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 one unit for the first 30 minutes of the total, and a second unit for the last 20 minutes of 96040. “If the total time was 44 minutes, you would report one (1) unit for the first 30 minutes, and no other unit could be reported for the last 14 minutes, since the remainder was not equal to or greater than 16 minutes of time,” Loya says.

Question 5: What Do I Do If an Asymptomatic Patient Receives Genetic Counseling?

Answer 5: If the patient receiving genetic counseling lacks symptoms, you should consider a Z ICD-10-CM code. You’ll find specific Z codes for patients who have been tested and have a genetic probability: