Pathology/Lab Coding Alert

2-character modifier just might get you paid

You may not be using them yet, but CPT's new genetic test modifiers can help your lab show medical necessity for genetic studies, which can ease reimbursement.

Because CPT Codes describe only the lab process, coding couldn't indicate what genetic mutation you were testing for - until now. And because insurers didn't know what you were testing for, they were sometimes reluctant to pay.

Genetic-test coding will continue to specify the lab procedure using the same CPT codes you've always used. But now, with nearly 85 modifiers added in CPT 2005, you can also provide more information about the genetic condition and the test's purpose. Using the modifiers, however, won't affect the amount of a procedure's payment.

Learn the Numeric-Alpha Distinction

The new genetic testing code modifiers are two-character numeric/alpha codes. "An appendix in CPT 2005 organizes new modifiers for specific genetic tests based on specific disease categories," says Laurie Castillo, CPC, CPC-H, CCS-P, owner of Castillo Consulting in Manassas, Va. Different versions of the CPT manual list the modifiers in different appendixes. The following groupings make up the numeric component of each two-digit modifier:

 0 and 1 - Neoplasia (solid tumor)

 2 - Neoplasia (lymphoid/hematopoetic)

 3 - Non-neoplastic hematology/coagulation

 4 - Histocompatibility/blood typing

 5 - Neurologic/non-neoplastic

 6 - Muscular, non-neoplastic

 7 - Metabolic, other

 8 - Metabolic, transport

 9 - Metabolic-pharmacogenetics; Dysmorphology

For each category, CPT lists numeric/alpha modifiers specific for established gene mutations. The numeric digit indicates the disease category, and the alpha character specifies gene type. CPT reserves the letter "Z" for not-otherwise-specified (NOS) genetic mutation within each disease-type category.

Using the modifiers allows you to provide specific information about a genetic test your lab performs without changing the way you use CPT procedure codes. "With the explosion in genetic testing, creating the two-digit modifier system provides the potential to describe 260 specific genetic mutations without adding new CPT codes for each," says Diana Voorhees, MA, CLS, MT(ASCP)SH, CLCP, principal with DV & Associates Inc. in Salt Lake City.

Modifiers for some common tests include 0A for BRCA1 (hereditary breast/ovarian cancer), 0I for Her-2/neu, 3A for Factor V (Leiden, others; Hypercoagulable state), and 8A for CFTR (Cystic fibrosis mutations). See the Clip-and-Save Chart in an upcoming article for a complete list of the modifiers.

Use Modifiers With Codes for Specific Genes

CPT directs you to use these modifiers "with molecular laboratory procedures related to genetic testing." You'll find introductory guidelines for using the new modifiers at the start of the cytogenetic studies section for codes 88230-88299, which may involve tests for oncologic or inherited disorders. CPT also places the modifier guidelines with molecular diagnostic codes 83890-83912, which labs often perform to investigate genetic components of infectious disease, oncology, hematology, neurology and inherited disorders.

But you probably won't use the modifiers with all of these codes all of the time because a code may describe a procedure that is not specific to one genetic mutation. "For example, when the lab performs an extraction, it may use the DNA sample to study more than one gene sequence," Voorhees says.

Guiding principle: "You should only use a genetic modifier with a code that describes a procedure related to a single, specific genetic mutation," Voorhees says. "That typically includes codes related to nucleic acid probes and mutation identification." Probe and identification codes that will likely take a genetic modifier include the following:

 83896 - Molecular diagnostics; nucleic acid probe, each

 83903 - ... mutation scanning, by physical properties (e.g., single strand conformational polymorphisms [SSCP], heteroduplex, denaturing gradient gel electrophoresis [DGGE], RNA'ase A), single segment, each

 83904 - ... mutation identification by sequencing, single segment, each segment

 83905 - ... mutation identification by allele specific transcription, single segment, each segment

 83906 - ... mutation identification by allele specific translation, single segment, each segment.

Don't Modify Codes for Multiple Genes

When performing molecular diagnostics tests, labs carry out various steps such as extracting and isolating genetic material, transferring or amplifying specific nucleic acid sequences, and detecting mutations. Each code in the 83890-83912 range represents a single process, and the lab will use many of the steps for a single molecular diagnostics study. Such a study could involve evaluation of one or multiple genetic mutations.

"When labs perform any of these steps to study multiple mutations, you need not report them with a genetic testing modifier," Voorhees says. That often includes steps such as extraction, amplification and interpretation. Based on whether the lab uses the following codes for a single- or multiple-mutation study, you might or might not append the new genetic testing modifiers:

 83890 - Molecular diagnostics; molecular isolation or extraction

 83891 - ... isolation or extraction of highly purified nucleic acid

 83892 - ... enzymatic digestion

 83893 - ... dot/slot blot production

 83894 - ... separation by gel electrophoresis (e.g., agarose, polyacrylamide)

 83897 - ... nucleic acid transfer (e.g., Southern, Northern)

 83898 - ... amplification of patient nucleic acid (e.g., PCR, LCR), single primer pair, each primer pair

 83901 - ... amplification of patient nucleic acid, multiplex, each multiplex reaction

 83902 - ... reverse transcription

 83912 - ... interpretation and report.

Example: The lab performs a single-site DNA analysis for known mutations for BRCA1/BRCA2 using the following steps. The code assignments show how you should now use the new genetic testing modifiers,  Voorhees says:

 extraction for BRCA1 and BRCA2 - 83890

 gel electrophoresis for BRCA1 - 83894-0A

 gel electrophoresis for BRCA2 - 83894-0B

 mutation sequencing identification for BRCA1 - 83904-0A

 mutation sequencing identification for BRCA2 - 83904-0B

 nucleic acid amplification for BRCA1 and BRCA2 - 83898

 interpretation - 83912.

New way: Notice that you no longer report units for codes such as 83894 if you list each test separately with the appropriate genetic-testing modifier.

Do this: Use the genetic testing modifiers in a similar fashion for cytogenetic studies. "You can use the new modifiers with codes 88271 through 88275 when they describe a test for a specific genetic mutation," Voorhees says.

 88271 - Molecular cytogenetics; DNA probe, each (e.g., FISH)

 88272 - ... chromosomal in situ hybridization, analyze 3-5 cells (e.g., for derivatives and markers)

 88273 - ... chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions)

 88274 - ... interphase in situ hybridization, analyze 25-99 cells

 88275 - ... interphase in situ hybridization, analyze 100-300 cells.

Should You Be Using Genetic Testing Modifiers?

CMS doesn't now require the genetic testing modifiers, but you should check with your other payers to determine if they require or encourage their use. Voorhees reports that some payers are instructing labs to use the modifiers. "But to avoid possible confusion and computer glitches, I wouldn't rush into using these modifiers until I received payer instructions," Voorhees says.

As insurers warm up to the new system, your lab could benefit by using these modifiers to show medical necessity for genetic tests. CPT says that using the modifiers should "provide ... specific information to allow payers to adjudicate claims." For payers that request the modifiers, using them should help you get paid now. And for everyone else, data-tracking made possible by these modifiers may improve genetic-testing coverage in the future.