Pathology/Lab Coding Alert

Question: A provider ordered a full gene sequence analysis of BRCA2 plus a BRCA1 known familial variant for the patient. We performed the testing using NGS. Should we bill this as 81163?

Texas Subscriber

Answer: No, you should not report 81163 (BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis) for the testing you described. You’re not doing a full gene sequence analysis for BRCA1, so using that code would be overbilling.

What you’ve described is a single next generation sequencing (NGS) procedure that evaluates multiple genes but does not have a specific CPT^® code. You should report this unique test using 81479 (Unlisted molecular pathology procedure).

The National Correct Coding Initiative (NCCI) Policy Manual, chapter 10 section F-8 states “If one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT^® code. If no CPT^® code accurately describes the procedure performed, the laboratory may report CPT^® code 81479 (Unlisted molecular pathology procedure) with one unit of service …”

Caveat: The NCCI Policy Manual goes on to offer the option, “… or [the laboratory] may report multiple individual CPT^® codes describing the component test results …” That may lead you to believe that you could report the service using the following two codes:

• 81216 (BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis)
• 81215 (BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant)

Problem: NCCI edits list 81216 as a column 2 code for 81215 with a modifier indicator of 1, meaning that you cannot override the edit pair under any circumstances.