Pathology/Lab Coding Alert

CPT® 2024:

Spotlight Blood and Tumor Cancer Coding With New and Revised Codes

Published on Fri Nov 10, 2023

Use this glossary for better understanding.

You’ll find a host of CPT^® 2024 updates that focus on how you should report molecular testing for solid organ tumors and blood cancers next year.

To get the most out of the changes, you need to be familiar with the following terms:

Cell–free nucleic acid: DNA or RNA fragments normal or tumor cells that enter the bloodstream and may be isolated for molecular or other diagnostic tests.
Copy number variant (CNV): Change in the number of copies of a certain gene sequence, usually due to duplications or deletions.
Duplication and/or deletion: Increase and/or decrease in the normal copy number, which is two copies of a gene sequence.
Gene rearrangements: Change in the order of gene sequences on a chromosome, such as an “insertion” out of the normal order or “translocation” to a different location.
Hematolymphoid neoplasm: Cancer of blood, bone marrow, or lymph organs, such as leukemias and lymphomas.
Microsatellite instability (MSI): The tendency of genes to mutate due to impaired DNA mismatch repair (MMR).
Nucleic acid: A sequence of specific biological chemicals (nucleotides) that carry genetic information; known as deoxyribonucleic acid (DNA) or ribonucleic acid (RNA).
Sequence variant: Gene that differs from the usual nucleic acid sequence.
Tumor mutation burden (TMB): A measure of the amount of change (genetic mutations) present in the DNA of cancer cells.

Check Out New Codes

Greet the following six codes introduced in CPT^® 2024 for reporting genomic sequence analysis panels for solid organ cancers:

81457 (Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability)
81458 (… DNA analysis, copy number variants and microsatellite instability)
81459 (… DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements)
81462 (Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements)
81463 (… DNA analysis, copy number variants, and microsatellite instability)
81464 (… DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements)

Notice that the new codes introduce tumor microsatellite instability testing, says Kristen Taylor, CPC, CHC, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services. This involves evaluating the length of certain DNA segments to see if they’ve gotten longer or shorter, indicating instability, or a tendency to mutate.

The codes also introduce tumor mutational burden testing to evaluate the level of mutation already present in the cancer cell DNA.

Cell free: Notice that codes 81462-81464 use cell-free nucleic acid (DNA or RNA) circulating in blood as the specimen source, compared to codes 81457-87459, which use tumor tissue as the specimen source. “The cell-free nucleic acid tests allow non-invasive genomic sequence analysis for solid tumors,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas.

Don’t Miss Revisions

CPT^® 2024 also revises the following six existing genomic sequence analysis panel codes for solid organ and hematolymphoid cancers:

81445 (Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis)
81449 (… RNA analysis)
81450 (Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis)
81451 (… RNA analysis)
81455 (Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis)
81456 (… RNA analysis)

The revised definitions now lead with the neoplasm type and drop the parenthetic gene list. These are minor changes that shouldn’t alter how you use the codes.

Back story: Codes 81445, 81450, and 81455 describe testing for DNA analysis or combined DNA and RNA analysis, but don’t allow for stand-alone RNA analysis. CPT^® 2023 added the child codes 81449, 81451, and 81456 because there was a need for separate codes for RNA distinct from DNA testing, according to Jan A. Nowak MD, PhD, FCAP, representing The College of American Pathologists in his presentation at the Clinical Laboratory Fee Schedule (CLFS) annual meeting regarding the addition of the codes.

Use Guidelines’ Decoder Table

Now that you have 12 codes for solid organ and/or hematolymphoid cancer genomic sequence analysis, choosing the correct code may be confusing.

Help is here: The CPT^® 2024 guidelines for Genomic Sequencing Procedures and Other Molecular Multianalyte Assays adds a table that will help you sort it all out.

The table allows you to distinguish the codes based on cancer type (solid organ or hematolymphoid), specimen type (whether cell–free), nucleic acid type (DNA and/or RNA), and mutation information such as sequence variants, copy number variants, rearrangements, MSI, and TMB.

Keep on Eye on PLA Codes

In addition to the revised and new Category I codes discussed above, CPT^® 2024 also includes the following new codes Proprietary Laboratory Analyses (PLA) codes for genomic solid or hematolymphoid neoplasm genomic sequence analysis:

0379U (Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden)
0409U (Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability)
0413U (Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterations)

Remember: Each PLA code describes a unique lab test performed by a specific lab or produced by a specific manufacturer. If your lab performs the PLA test, you must use the PLA code, which takes precedence over Category I codes with similar descriptors.