Billing and Coding: Molecular Pathology and Genetic Testing

Medicare pays for molecular pathology and genetic tests only when they are reasonable and necessary for management of a beneficiary and provide new clinical diagnostic information not obtainable by other tests. Screening tests, carrier screening, prenatal diagnostics, pre-symptomatic tests, investigational tests not in trials, and tests without diagnosis-specific indications are not covered; robust documentation linking each billed code to clinical necessity (including specific claim fields for CPT 81479) is required and lack of documentation or inappropriate stacking/unbundling will result in denial.

"A molecular or genomic test may be covered when it provides new clinical diagnostic information that cannot be obtained from any other test or combination of tests and is reasonable and necessary f..."

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