January 24, 2013

Molecular Pathology Leads the Way in 2013 CPT Changes

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A look at the pathology and laboratory section of the 2013 CPT code book reveals a lot of green text, which means, of course, that the American Medical Association (AMA) added or revised many instructional notes. This is especially true in the section devoted to tier 2 molecular pathology procedures where all of the codes (81400–81408) include changes of some sort.  Also included is new code 81479 for reporting an unlisted molecular pathology procedure.

The AMA introduced many of the new codes for molecular pathology last year, but most laboratories did not implement them due to lack of clear guidance by payers and lack of Medicare payment. In 2012 laboratories continued to report the “stacking codes” in CPT range 83890–83914, but the AMA deleted this set of codes for 2013 with instructions for coders to reference codes 81200–81479—a range that includes 14 new codes and 9 revised codes.

Every laboratory will need to review the new codes in the 812XX–815XX series and determine which existing procedures on the chargemaster must be mapped to one of the new gene- or disease-specific CPT codes. Even hospitals that do not perform molecular diagnostic testing in-house may receive orders and referrals, and the facility will need to bill the procedure. This is a significant remapping of CPT codes that should occur now since coding changes should have been in place on January 1, 2013.

Most Important: Educate Ordering Providers

Providers who order the new molecular pathology tests should be informed about the specificity of information that is needed when ordering tests. Some gene studies require selection based on family history, most common variant, etc. Laboratories will not be able to accept a generic reference to a gene profile that is historically seen for scenarios such as pre-natal screen or congenital screening. Revise materials such as genetic counseling letters, request formats, order-entry screens, and charge description master (CDM) line items.

Note that labs should also review medical-necessity policies and reimbursement policies of both government and commercial payers. Many laboratories may find that testing that has, in the past, been reimbursed will now be denied as non-covered due to its designated status of investigational or experimental. 

When billing the stacking codes, which provided no payer insight to the specific purpose of the testing, labs did not closely monitor the coverage policies of the individual payers.  However, now that the unique code set for molecular pathology will communicate more specific information, especially when combined with the diagnosis submitted, laboratories will become aware of limitations associated with tumor markers and genetic screening.

Summary of Code Changes

Tier 1 Molecular Pathology. This procedure section got off easy in relation to the revisions, but the AMA added the 13 new codes below.

81201 APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence
81202 known familial variants
81203 duplication/deletion variants
81235 EGFR (epidermal growth factor receptor) (e.g., non-small cell lung cancer) gene analysis, common variants (e.g., exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q)
81252 GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (e.g., nonsyndromic hearing loss) gene analysis; full gene sequence
81253 known familial variants
81254 GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (e.g., nonsyndromic hearing loss) gene analysis, common variants (e.g., 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S1854)])
81321 PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis
81322 known familial variant
81323 duplication/deletion variant
81324 PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis
81325 full sequence analysis
81326 known familial variant

Multiple Assays.In 2013 there also are significant changes for procedures that utilize multiple assays in conjunction with pertinent patient information to calculate a result of probability. Included in the listing of assays most likely to be included in the algorithm are molecular pathology, fluorescent in-situ hybridization, and non-nucleic acid-based assays.

Coding professionals will need to consult this new subsection entitled Multianalyte Assays with Algorithmic Analyses (MAAA) when they assign codes for some tumor marker assays and fetal screenings. When billing for an algorithmic result, the MAAA code will be the only CPT billed.  Do not report the procedural codes in addition.

Along with new codes 81500—81512 listed below, there’s unlisted MAAA code 81599.  Make note that the unlisted MAAA code does not include a “per analysis” reference or any other unit of service reference. The AMA’s instructions appear to indicate that a CPT code in this section should be billed once per date of service even if you perform multiple analyses that qualify for reporting of the CPT 81599.


 

For 2013, the AMA deleted CPT codes 88384–88386 (micro-array procedures), and laboratories must now report the most appropriate molecular pathology (81200–81479) or MAAA CPT codes. The micro-array analysis is no longer separately billable.

81500 Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score
81503 Oncology (ovarian), biochemical assays of five proteins (CA-125, apoliproprotein A1, beta-2 microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score
81506 Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbA1c, insulin, hs-CRP, adoponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score
81508 Fetal congenital abnormalities, biochemical assays of two proteins (PAPP-A, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score
81509 Fetal congenital abnormalities, biochemical assays of three proteins (PAPP-A, hCG [any form], DIA), utilizing maternal serum, algorithm reported as a risk score
81510 Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG [any form]), utilizing maternal serum, algorithm reported as a risk score
81511 Fetal congenital abnormalities, biochemical assays of four analytes (AFP, uE3, hCG [any form], DIA) utilizing maternal serum, algorithm reported as a risk score (may include additional results from previous biochemical testing)
81512 Fetal congenital abnormalities, biochemical assays of five analytes (AFP, uE3, total hCG, hyperglycosylated hCG, DIA) utilizing maternal serum, algorithm reported as a risk score
81599 Unlisted multianalyte assay with algorithmic analysis

Immunology and Tissue Typing. The immunology subsection now has the following new codes:

86152 Cell enumeration using immunologic selection and identification in fluid specimen (e.g., circulating tumor cells in blood);
86153 physician interpretation and report, when required

Yet more new codes were added for tissue-typing assays:

86828 Antibody to human leukocyte antigens (HLA), solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I and Class II HLA antigens
86829 Antibody to human leukocyte antigens (HLA), solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); qualitative assessment of the presence or absence of antibody(ies) to HLA Class I or Class II HLA antigens
86830 Antibody to HLA, solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); antibody identification by qualitative panel using complete HLA phenotypes, HLA Class I
86831 Antibody to HLA, solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); antibody identification by qualitative panel using complete HLA phenotypes, HLA Class II
86832 Antibody to HLA, solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); high definition qualitative panel for identification of antibody specificities (e.g., individual antigen per bead methodology), HLA Class I
86833 Antibody to HLA, solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); high definition qualitative panel for identification of antibody specificities (e.g., individual antigen per bead methodology), HLA Class II
86834 Antibody to HLA, solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); semi-quantitative panel (e.g., titer), HLA Class I
86835 Antibody to HLA, solid phase assays (e.g., microspheres or beads, ELISA, flow cytometry); semi-quantitative panel (e.g., titer), HLA Class II

Microbiology. Coders will find revisions to the descriptions for the following codes: 87498, 87521, 87522, 87535, 87536, 87538, 87539, and 87901. This section also includes the five code additions listed below related to infectious agent detection. Of particular interest to many hospitals and independent laboratories will be the new codes for respiratory virus detection by amplified probe technique, which CPT did not clearly define in previous years.

87631 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 3–5 targets
87632 respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 6–11 targets
87633 respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 12–25 targets
87910 Infectious agent genotype analysis by nucleic acid (DNA or RNA); cytomegalovirus
87912 Hepatitis B virus

About the Author

Randy Wiitala is vice president, clinical consulting services—pharmacy, for Panacea Healthcare Solutions, Inc., St. Paul, MN.

Contact the author

rwiitala@panacea.com

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Randy Wiitala, BS, MT (ASCP)

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