Oncology & Hematology Coding Alert

Here’s how to find all the history and encounter codes you need quickly and easily.

Before someone decides to undergo genetic testing to determine whether they have an inherited risk of cancer or after that person has been genetically tested, it is common for them to undergo some form of counseling. That way, the person can understand the risks and benefits of the tests themselves or understand what the test results have revealed about their risk for cancer.

Assigning the correct procedure and diagnosis codes associated with the service is not hard providing you follow these three simple steps and be mindful of both patient and provider status at every point in the process.

Step 1: Code the Service by Provider, Patient Status

The first step in coding these services correctly is choosing the correct code for the service. If you have a member of staff who is a Certified Genetic Counselor (CGC), credentialed by the American Board of Genetic Counselors (ABMG) (www.abgc.net), you can document the services with 96040 (Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family).

Reminder: Consistent with CPT^® general instructions for time-based coding, which tell you that “a unit of time is attained when the mid-point is passed,” the guidelines for 96040 remind you that you can only report the code once the counseling has passed the 15-minute mark. You cannot report counseling lasting 15 minutes or less.

So, you’ll report one unit of 96040 for a counseling session lasting 16-30 minutes, an additional unit for a session lasting from 46-60 minutes, and so on.

The code is only for services provided by a trained genetic counselor. When a physician or other qualified health care professional who may report evaluation and management (E/M) services counsels a patient without symptoms or an established disease, CPT^® tells you to choose the appropriate E/M code from 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual (separate procedure) ...). And if that counseling is for an individual in a group, CPT^® tells you to use 99411-99412 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to individuals in a group setting (separate procedure) ...).

Unlike 96040, you will pick the preventive medicine code that most closely matches the amount of time your provider spends counseling the patient up to 60 minutes.

Step 2: Document the Services Provided

To document 96040, you will need to show that some or all of the following took place:

• The counselor obtained a structured family genetic history;
• The counselor constructed a pedigree chart;
• The counselor provided an analysis for genetic risk assessment; and
• The counselor provided counseling for the patient and family.

CPT^® guidelines note you can also count time the counselor spends reviewing medical data and family information toward 96040.

Step 3: Use the Appropriate ICD-10-CM Codes

Perhaps the trickiest part of coding for genetic counseling is providing the correct diagnosis codes to justify the services. That’s because there are a lot of variables in each patients’ circumstances to consider. However, the following coding sequence will help you determine which codes to apply.

Cancer code: If the patient has previously been diagnosed, the first ICD-10-CM code you will use will be the appropriate neoplasm code from C00-D49.

Personal/family history code: You’ll choose the next applicable code from either Z80.- (Family history of primary malignant neoplasm) or Z85.- (Personal history of malignant neoplasm), using the appropriate fourth and fifth digits to identify which body system or part was previously affected.

Per ICD-10-CM guideline C.21.c.4, you will use the personal history code to “explain a patient’s past medical condition that no longer exists and is not receiving any treatment” which you can use “in conjunction with follow-up codes.” If the patient “has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease,” then you will use a family history code “in conjunction with screening codes to explain the need for a test or procedure.”