Tuesday, January 5, 2016

Medicare Says: Don't Bill Single Gene Codes along with Tumor Gene Panel Codes

Since 1996 Medicare has published "procedure to procedure" edits, which are large excel spreadsheets showing which codes should not be used together, because they are exclusive or because one is encompassed by the other.  For 1/1/2016, Medicare has block used of single gene (and "Tier 2") genomic codes if tumor gene panel codes are used on the same claim.

Medicare's Procedure to Procedure edits are on a public website and downloadable as Excel spreadsheets (here).  There are two main types.  "Medically Unlikely" edits are directed to volume: e.g. it is "medically unlikely" you would have more than one appendectomy in a day.  But Medical also views it as medically unlikely you would have more than 2, 4, or some other number of various tests and procedures.   The second type is "Procedure to Procedure" coding edits.  For example, these will block the billing of "laceration repair" with "appendectomy" because surgical closure is part of an appendectomy.

AMA CPT has three tumor gene panel codes, 81445 for 5-50 solid tumor genes, 81450 for lymphoid/hematopoetic neoplasms with 5-50 genes, and 81455 for any cancer, 51+ genes.   For January 1, 2016, CMS added several hundred edits to the 81445/50/55 codes.  Use of these codes blocks (is taken to include) a couple hundred single gene sequencing codes, as well as MAAA codes as well as a few other codes, newly effective this week.

For pre-Christmas instructions from MolDX on how it interprets or allows use of 81445/50/55, see an earlier blog (here).