Pathology/Lab Coding Alert

Look for coverage opportunities.

More and more labs are offering genetic tests to aid physicians in diagnosis and prognosis of diseases, including genetic carrier status. To capture the pay your lab deserves, you need to understand CPT^® test code options, as well as additional services such as genetic counseling.

Read the following genetic testing Q&As to get the lowdown on getting paid for these services.

Question 1: Grasp Types of Genetic Lab Tests

Q: Will I always find the correct genetic test code for a lab test in the Molecular Pathology CPT^® section that includes codes in the range 81105-81408?

A: No, Molecular Pathology (MP) codes 81105-81408 are not the only codes in CPT^® that describe procedures that labs might perform for genetic testing.

The codes in the MP section describe Tier 1 tests for variant(s) of a specific listed gene or genes, such as 81210 (BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s)).

The MP section also includes Tier 2 codes that describe less-frequently ordered tests. “These codes are based on the level of resources required for the test, but list specific genes as part the code definition,” explains William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. For instance, 81406 (Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variant…) includes a listed test for ANOS1 (anosmin-1) (e.g., Kallmann syndrome 1), full gene sequence analysis.

That’s not all: CPT^® also has a section that describes more comprehensive genetic testing involving genomic sequencing procedures (GSPs) that evaluate genes relevant to a specific clinical condition. You’ll find these codes in the range 81410-81471 describing tests that involve analysis of many more than a single gene, often an entire region, exome, or genome. The tests described by these codes often include evaluation of a gene that also has a specific test code in the MP section, and you should not report the two codes together.

For instance, 81435 (Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include sequencing of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11) interrogates 10 genes, including MSH61. Code 81298 (MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis) describes full gene sequence analysis for MSH61. You should, therefore, not report those two codes together.

There’s more: The Multianalyte Assays with Algorithmic Analyses (MAAA) CPT^® section (codes 81490-81599) describes assays that use multiple test and panel results, possibly genetic test results, and analyzes the results using an algorithm to arrive at a risk score. Like GSPs, MAAA codes might include testing for specific genes that a Tier 1 or Tier 2 test also describes, and you should not report the codes together. CPT^® also includes more MAAA tests that do not already have a Category 1 code in Appendix O. The additional descriptors are for administrative codes that take the form of four digits and the letter M, such as 0011M.

Finally: The last Pathology and Laboratory CPT^® 2019 section (codes 0001U-0061U) includes Proprietary Laboratory Analyses (PLAs), which are tests by one specific manufacturer performed in multiple labs, or tests provided by a single laboratory. Some of the PLA codes describe genetic tests that may have a similar Tier 1 code, such as PLA code 0027U (JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15) and Tier 1 code 81270 (JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant).

The PLA codes are specific for a single manufacturer or lab. For instance, 0027U describes the Mayo Clinic JAK2 Exons 12 to 15 Sequencing (JAKXR) test. PLA codes take priority over Category 1 codes, so even if the codes describe the same gene analysis, you must report the PLA code.

Question 2: Look for Counseling Service

Q: What is genetic counseling, who provides it, and how do I code it?

A: 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 that a trained genetic counselor provides. 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 unit of code 96040 for at least 16 minutes to 30 minutes of documented service. Code 96040 includes the following service:

• Obtaining a structured family genetic history
• Construction of a pedigree chart
• Analysis for genetic risk assessment
• Counseling of the patient and family.

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 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.

Physician exception: 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) and 99402 (… approximately 30 minutes).

Diagnosis: If an asymptomatic patient receives genetic counseling, you should consider an ICD-10-CM Z code such as one of the following:

• Z15.0- (Genetic susceptibility to malignant neoplasm)
• Z15.8- (Genetic susceptibility to other disease)
• Z36- (Encounter for antenatal screening of mother).