Billing and Coding: Molecular Pathology Procedures
A59926
Molecular pathology panel tests must be billed using appropriate panel CPT codes (81445/81449/81450/81451 for 5–50 genes; 81455/81456 for ≥51 genes) rather than individual gene codes; 81479 may be used when no panel code exists and must be well-documented. Coverage varies by CPT/HCPCS group: Group 1 and Group 4 may have limited coverage, Group 2 requires individual review with documentation of medical necessity, and Group 3 is non-covered; screening and pre-symptomatic tests are excluded. Documentation requirements include a physician requisition with ICD-10 diagnosis, medical-record evidence that testing will influence management, specific laboratory and LDT documentation if requested, correct use of Modifier 91, and reporting of ordering/referring physician name and NPI on the claim.
"When 5–50 genes are ordered as a molecular testing panel, bill the appropriate panel CPT code (81445, 81449, 81450, or 81451) rather than individual single-gene CPT codes."