Wednesday, December 26, 2018

(Weblink for post in error)

On Dec 26-27, this link held an erroneous post that CMS had deleted some unusual coding rules for genetic testing, rules that were released on Nov 22.  

While CMS made other policy updates on Dec 12, CMS did NOT change the genetic coding rules.

See original post about the new 2019 genetic coding rules here.

I list the new November rules (for 2019) for genetic tests below.  Thereafter, I also list a potentially important update to the Panel rules (if components of a panel are performed, lab SHALL bill that panel code.)   This latter update was December 12 (for 2019).  The December update on panel billing likely reflects the GAO report that CMS was overpaying for components of panel testing in some circumstances.


7. A Tier 1 or Tier 2 molecular pathology procedure CPT 
code  shall not be reported with a genomic sequencing procedure, 
molecular multianalyte assay, multianalyte assay with 
algorithmic analysis, or proprietary laboratory analysis CPT 
code where the CPT code descriptor includes testing for the 
analyte described by the Tier 1 or Tier 2 molecular pathology 

8. If one laboratory procedure evaluates multiple genes 
utilizing 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 shall report CPT code 81479 (unlisted 
molecular pathology procedure) with one unit of service.  The 
laboratory shall not report multiple individual CPT codes 
describing the component test results.  If a single procedure is 
performed, only one HCPCS/CPT code with one unit of service may 
be reported for the procedure. 

9. Procedure-to-procedure edits bundling two Tier 1 
molecular pathology procedure CPT codes describe procedures that 
should not routinely be performed and reported together.  For 
example CPT code 81292 describes full sequence gene analysis of 
MLH1, and CPT code 81294 describes duplication/deletion variant 
gene analysis of MLH1.  In evaluating a patient with colon 
carcinoma (vs. constitutional genetic disorder), it may be 
appropriate to perform duplication/deletion testing if the 
disease variant(s) is (are) not identified by performing full 
gene sequencing.  The same principle applies to other code pair 
combinations of testing for the same gene (e.g., 81295/81297, 

Word "should" changed to "shall"

The CPT Manual assigns CPT codes to organ or disease oriented
panels consisting of groups of specified tests.  If all tests of
a CPT defined panel are performed, the provider shall bill the
panel code.  The panel codes shall be used when the tests are
ordered as that panel. For example, if the individually ordered
tests are cholesterol (CPT code 82465), triglycerides (CPT code
84478), and HDL cholesterol (CPT code 83718), the service shall
be reported as a lipid panel (CPT code 80061)