Pathology/Lab Coding Alert

Check out Tier 2 to Tier 1 conversions.

CPT^® 2021 introduces 16 new Tier 1 molecular pathology codes that you need to know effective Jan. 1.

Because more than half the codes describe tests that have been listed under Tier 2 codes, knowing the new code numbers and descriptors won’t be enough to keep your claims clean. We’re here to help you identify the gene tests that “converted” from Tier 2 so that you can stop using those codes when billing these tests.

Context: Gene name(s) drive your code selection for most molecular pathology testing. Tier 1 codes in the range 81105-81364 (with many codes out of numerical sequence) list genes in alphabetical order from ALB1 to ZRSR2. Tier 2 codes (81401-81408) describe less-common tests organized by increasing levels of required resources (Levels 1 through 9). Within each level, CPT^® also lists genes alphabetically, and you should code the appropriate Tier 2 code only for a listed gene. For any gene analysis not listed in Tier 1 or Tier 2, report 81479 (Unlisted molecular pathology procedure).

Add This Table to Your Toolkit for New MoPath Codes

Use the following table to summarize the new Tier 1 codes, their potential use, and their relationship to Tier 2 revisions in CPT^® 2021.

Enhance Cancer Detection

Of the 16 new Tier 1 molecular pathology codes, most describe tests for somatic mutations associated with neoplasia.

“These new codes allow for an increase in the number and specificity of genes being analyzed, which enhances cancer screening opportunities,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina.

Blood cancers: Multiple new codes allow clinicians to order tests that can help guide diagnoses, prognosis, and treatment options for blood cancers, such as the following:

• 81168 and 81278 for lymphomas
• 81279, 81338, and 81339 for myeloproliferative neoplasms
• 81191-81194 for solid tumors involving activated TRK proteins that don’t turn off, leading to tumor growth
• 81347, 81348, 81357, and 81360 for genes associated with myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML)

Focus Germline Mutations

One new Tier 1 molecular pathology code family informs clinicians about germline mutations, which impact heritable constitutional disorders, rather than somatic mutations involved in a particular cancer.

Codes 81351-81353 describe analyses of the TP53 (tumor protein 53) gene, including full gene sequence, targeted sequence, and known familial variant tests. Inherited mutations in the TP53 gene can cause Li-Fraumeni syndrome. TP53 is a tumor suppressor gene, and mutations to the gene may allow uncontrolled cell growth contributing to many types of cancer. Clinicians may use this series of tests to diagnose the condition, or for predictive testing to allow early cancer screenings for individuals with mutations implicating early onset of cancers.

Prior to introducing these three new codes, CPT^® provided two Tier 2 codes for TP53 testing. Codes for TP53 are now deleted from 81404 (MoPath Level 5) and 81405 (MoPath, Level 6), according to Lee Hillborne, MD, MPH, professor of pathology and laboratory medicine, UCLA school of medicine and senior medical director, medical affairs, Quest Diagnostics in his CPT^® and RBRVS 2021 Annual Symposium presentation.

Monitor Tier 2 Revisions

Each year, CPT^® may delete gene tests from Tier 2 code lists. Commonly, this change is due to the test experiencing increased usage that justifies conversion to a Tier 1 code, but a test may be removed for lack of clinical use.

Additions: CPT^® may also add new gene tests to the Tier 2 code lists each year, so you need to be on the lookout for those changes. If CPT^® adds a specific gene to a Tier 2 code list, you’ll need to start reporting that code instead of unlisted code 81479 for the test.

2021: The deletions identified in the preceding table represent the only changes made to Tier 2 molecular pathology codes in CPT^® 2021. No new genes are added to the test lists under each code in the range 81401-81408.