Billing and Coding: Molecular Pathology and Genetic Testing

Medicare payment for molecular pathology and genetic testing requires that tests be reasonable and necessary, provide new diagnostic information not obtainable from other tests, and be ordered and used by a practitioner with an established relationship to manage a specific medical problem. Screening tests without signs/symptoms, carrier screening, prenatal diagnostic testing, many presymptomatic tests, investigational tests not in clinical trials, and tests relevant only to newborns/early childhood are excluded and will be denied. Claim submissions must use the most accurate CPT code (Tier 1 preferred), include specific gene/analyte information for Tier 2 (CPT 81400–81408) and unlisted CPT 81479 (with claim block/box entries), and must have medical-record documentation linking each billed code to the service performed.

"Advanced diagnostic laboratory tests (ADLTs) are allowable only when they provide new clinical diagnostic information that cannot be obtained from any other test or combination of tests (per 42 CFR..."