Reimbursement News - New CPT Codes Proposed!!

Appropriate billing codes pave the way for reimbursement
American College of Medical Genetics Committee on the Economics of Genetic Services

Submitted by Michael S. Watson, PhD, Washington University School of Medicine

The ACMG Committee on the Economics of Genetic Services has been actively assessing the state of billing and reimbursement for genetic services. Two surveys captured the general understanding of our membership about billing and reimbursement issues. It was determined that we all need a lot of education about this critical area. In the utilization of ICD9 and CPT codes, approximately 1/3 of the survey respondents indicated that they use codes leading to significantly lower levels of reimbursement than is justified based on the actual service provided.

The Committee has already submitted a proposal to the American Medical Association (AMA) CPT Editorial Panel to revamp CPT codes for genetic testing and counseling. Following a comment period during which other practice areas which may use the same codes are allowed to present their view of our proposal, the Panel may choose to approve all or some codes, request additional information to support parts of the proposal, or reject all or parts of the proposal. Those codes which are accepted will then be incorporated into CPT 1997. Below are the proposed CPT codes for each area. Remember that the proposed codes are NOT to be used until they have been approved. Look for notification from the ACMG Economics Committee when we can use the codes.

In addition, over the next 6-9 months, the ACMG Economics Committee will be preparing proposals to the AMA RBRVS (Resource Based Relative Value Scales) Update Committee for change in the reimbursement of genetic services. Although we have collected a limited amount of cost analysis data for services of all types, we can always use more. If any genetics program has cost analysis data for service provided by laboratories or clinical service, the committee could use additional information to support our request for a reconsideration of the caps currently placed on reimbursement from public funds for the services provided. It is expected that the ACMG soon will have an integrated network of state and regional representatives to facilitate communication about these issues and activities. As efforts culminate at the national level, ways of moving these efforts to the state level will be available.

In an effort to provide educational opportunities to members, we have added a workshop on reimbursement to the ACMG meeting in March. This will be delivered by a private consulting group with experience in the billing, collections and quality management of billing for health care services and for genetic services. Participation will be on a first-come first-serve basis for the two sessions currently planned on March 10, 1996. Please contact the ACMG office for additional information.

It is essential that we begin to integrate medical genetics, both clinically and administratively, into the standard health care delivery system. Changes in health care are occurring at a rapid pace with the greatest changes being in the continuing expansion of managed care. If genetics is not well recognized and accurately structured in the current system, it will be poorly integrated into managed care. We already see evidence of exclusion of geneticists within managed care providers. Similarly, as the service providers most familiar with the rapid evolution of the technologies employed in medical genetics, we must be particularly active in ensuring that new technologies and services are promptly integrated into existing structures.

Proposed CPT Codes
N=New M=Modified U=Unchanged

Biochemical Genetics

  1. (N)- tissues for biochemical genetic analysis; blood cells
  2. (N)- cultured cells (eg, fibroblasts)
  3. (N)- plasma, serum
  4. (N)- solid tissue
  5. (N)- urine
  6. (N)- other body fluid
  7. (N)- amino acid analysis; single qualitative, each
  8. (N)- single analyte quantitative, each
  9. (N)- multiple analytes qualitative, each
  10. (N)- multiple analytes quantitative, each
  11. (N)- qualitative profile, each
  12. (N)- quantitative profile, each
  13. (N)- carnitine; total free or esterified, quantitation, each
  14. (N)- esters (acylcarnitines), qualitative profile, each
  15. (N)- esters (acylcarnitines), quantitative profile, each
  16. (N)- mucopolysaccharide profile; qualitative, each
  17. (N)- quantitation, each
  18. (N)- organic acid profile; qualitative, each
  19. (N)- quantitation, each
  20. (N)- sugar compounds (mono-, di-, and oligosaccharides); single qualitative, each
  21. (N)- single quantitation, each
  22. (N)- qualitative profile, each
  23. (N)- quantitative profile, each
  24. (N)- very long-chain fatty acids; quantitative profile, each

    Enzymology

  25. (N)- enzyme activity assay, analyte not specified elsewhere; artificial substrate, each
  26. (N)- natural substrate, each
  27. (N)- radioactive substrate, each
  28. (N)- biotinidase activity assay, each
  29. (U)- galactokinase
  30. (U)- galactose-1-phosphate uridyltransferase activity assay, each
  31. (U)- screen
  32. (U)- glucose-6-phosphate dehydrogenase activity assay
  33. (U)- screen
  34. (U)- b-Glucosidase activity assay, each
  35. (N)- b-Hexosaminidase activity assay, each
  36. (U)- electrophoresis, each assay; analyte not elsewhere specified
  37. (N)- gas chromatography (GC), analyte not elsewhere specified; single metabolite, qualitative, each
  38. (N)- single metabolite, quantitation, each
  39. (N)- multiple metabolites, qualitative, each
  40. (N)- multiple metabolites, quantitation, each
  41. (N)- gas chromatography/mass spectrometry (GC/MS), analyte not elsewhere specified; single metabolite, qualitative, each
  42. (N)- single metabolite, quantitation, each
  43. (N)- multiple metabolites, qualitative, each
  44. (N)- multiple metabolites, quantitation, each
  45. (N)- stable isotope dilution, single metabolite, quantitation, each
  46. (N)- stable isotope dilution, multiple metabolites, quantitation, each
  47. (N)- liquid chromatography (HPLC), analyte not elsewhere specified; single metabolite, qualitative, each
  48. (N)- single metabolite, quantitation, each
  49. (N)- multiple metabolites, qualitative, each
  50. (N)- multiple metabolites, quantitation, each
  51. (N)- liquid chromatography/mass spectrometry (HPLC/MS), analyte not elsewhere specified; single metabolite, qualitative, each
  52. (N)- single metabolite, quantitation, each
  53. (N)- multiple metabolites, qualitative, each
  54. (N)- multiple metabolites, quantitation, each
  55. (N)- mass spectrometry and tandem mass spectrometry (MS,MS/M), analyte not elsewhere specified; single metabolite, qualitative, each
  56. (N)- single metabolite, quantitation, each
  57. (N)- multiple metabolites, qualitative, each
  58. (N)- multiple metabolites, quantitation, each
  59. (N)- paper chromatography (PC), analyte not elsewhere specified; mono-dimensional, qualitative, each
  60. (N)- bi-dimensional, qualitative, each
  61. (N)- thin layer chromatography (TLC), analyte not elsewhere specified; single, qualitative, each
  62. (U)- profile, qualitative, each
  63. (N)- biochemical genetics, interpretation and reporting

Cytogenetics

  1. (M)- tissue culture for genetic testing, constitutional
  2. disorders; lymphocyte
  3. (M)- skin or other solid tissue biopsy
  4. (M)- amniotic fluid or chorionic villus cells
  5. (M)- tissue culture for genetic testing, acquired disorder (leukemia/cancer); bone marrow, blood cells, lymph nodes
  6. (M)- solid tumor
  7. (N)- freezing and short term storage of cell lines, each
  8. (N)- thawing and expansion of established cell cultures, each
  9. (M)- chromosome analysis for breakage syndromes; baseline SCE, 20-25 cells
  10. (M)- baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes, (AT, Fanconi, fragile X)
  11. (D)- merge into 88248 and delete
  12. (N)- score 100 cells, clastogen stress (e.g. DEB, MMC, ionizing radiation, UV radiation)
  13. (D)- chromosome analysis; count 5 cells, screening with banding (DELETE CODE)
  14. (U)- count 5 cells, 1 karyotype, with banding
  15. (U)- count 15-20 cells, 2 karyotypes, with banding
  16. (U)- count 45 cells for mosaicism, 2 karyotypes, with banding
  17. (N)- analyze 20-25 cells
  18. (U)- chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding
  19. (U)- chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies
  20. (N)- molecular cytogenetics; DNA probe (fluorescence labeled), each
  21. (N)- chromosomal in situ hybridization, analyze 3-5 cells (eg, derivatives and markers)
  22. (N)- chromosomal in situ hybridization, analyze 10-30 cells (eg, microdeletions)
  23. (N)- interphase in situ hybridization, analyze 25-99 cells
  24. (N)- interphase in situ hybridization, analyze 100-300 cells
  25. (U)- chromosome analysis; additional karyotypes, each study
  26. (U)- additional specialized banding technique (eg, NOR, C-banding)
  27. (U)- additional cells counted, each study
  28. (U)- additional high resolution study
  29. (N)- complex cytogenetics and molecular cytogenetics, interpretation and report 88299 Unlisted cytogenetic study

Molecular Diagnostics

  1. (M)- nuclear molecular diagnostics; nucleic acid isolation or extraction, semi-purified or simple
  2. (N)- nucleic acid isolation or extraction, purified or complex
  3. (U)- enzymatic digestion
  4. (N)- dot/slot blot production
  5. (N)- nucleic acid transfer (eg Southern, Northern)
  6. (M)- separation by gel electrophoresis (eg agarose, polyacrylamide)
  7. (U)- nucleic acid probe, each
  8. (M)- amplification of patient nucleic acid (eg, PCR,LCR, RT-PCR), single primer pair, each
  9. (N)- amplification of patient nucleic acid, multiplex, each
  10. (N)- hybridization and detection of molecular probe
  11. (N)- mutation identification, by physical properties, (eg SSCP, heteroduplex, DGGE, Rnase A, etc), single segment, each
  12. (N)- mutation identification by sequencing, single segment, each
  13. (N)- mutation identification by allele specific transcription, single segment, each
  14. (N)- mutation identification by allele specific translation, single segment, each
  15. (NC)- interpretation and report

Genetic Counseling

  1. Limited Genetics Counseling (approx. 15 min.)
  2. Intermediate Genetic Counseling (approx. 30 min.)
  3. Extended Genetic Counseling (approx. 45 min.)
  4. Comprehensive Genetic Counseling (approx. 1 hr.)
  5. Complex Genetic Counseling (In excess of 1 hr.)