How To Use CPT Code 96040

CPT 96040 refers to medical genetics and genetic counseling services provided by a trained nonphysician genetic counselor for 30 minutes face-to-face with the patient/family. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 96040 procedures.

1. What is CPT 96040?

CPT 96040 is a medical billing code used to represent medical genetics and genetic counseling services provided by a trained nonphysician genetic counselor. These services involve analyzing a patient’s family risk factors for genetic conditions, reviewing medical information, and counseling the patient and their family. The code is used to bill for every 30 minutes of face-to-face time spent with the patient and their family.

2. 96040 CPT code description

The official description of CPT code 96040 is: “Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family.”

3. Procedure

The 96040 procedure involves the following steps:

1. Collecting information about the patient’s genetic health, which may include reviewing medical records and interviewing family members.
2. Creating a family pedigree to assist with assessing genetic risks for the patient, who may or may not currently be exhibiting signs or symptoms of disease.
3. Coordinating tests for the patient, if necessary.
4. Creating a formal report including analysis and any recommendations.
5. Counseling the patient and family to help them understand the findings, management options, genetic risk within the family, and other related areas, including the emotions that surround diagnosis.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 96040 services include those with a family history of genetic conditions or those who are at risk of developing a genetic condition due to their family history. This may include patients with a family history of cancer, cardiovascular disease, or other hereditary conditions. Additionally, patients who are pregnant or planning to become pregnant and have concerns about potential genetic risks to their unborn child may also be eligible for these services.

5. When to use CPT code 96040

It is appropriate to bill the 96040 CPT code when a trained nonphysician genetic counselor provides medical genetics and genetic counseling services to a patient and their family for 30 minutes face-to-face. This code should be used for each 30-minute increment of time spent with the patient and their family. If the counseling session lasts longer than 30 minutes, additional units of the code should be billed accordingly.

6. Documentation requirements

To support a claim for CPT 96040, the following information should be documented:

• Patient’s medical and family history, including any known genetic conditions or risk factors.
• Details of the genetic counseling session, including the date, duration, and topics discussed.
• A formal report containing the analysis of the patient’s genetic risk factors, recommendations for further testing or management, and any other relevant information.
• Proof of the genetic counselor’s qualifications and training.

7. Billing guidelines

When billing for CPT code 96040, it is important to follow these guidelines:

• Ensure that the genetic counselor providing the service is a trained nonphysician professional.
• Bill one unit of the code for every 30 minutes of face-to-face time spent with the patient and their family.
• Document all necessary information to support the claim, as outlined in the documentation requirements section.
• Be aware of any payer-specific rules or guidelines that may apply to billing for genetic counseling services.

8. Historical information

CPT 96040 was added to the Current Procedural Terminology system on January 1, 2007. There have been no updates to the code since its addition.

9. Similar codes to CPT 96040

Five similar codes to CPT 96040 and how they differentiate from CPT 96040 are:

• CPT 99078: This code is used for genetic counseling and education provided to a group by a physician or other qualified health care professional.
• CPT 98961: This code is used for education regarding genetic risks by a nonphysician to a group of 2-4 patients.
• CPT 98962: This code is used for education regarding genetic risks by a nonphysician to a group of 5-8 patients.
• CPT 99401-99412: These codes are used for genetic counseling and/or risk factor reduction intervention provided to patients without symptoms or established disease by a physician or other qualified health care professional who may report evaluation and management services.
• CPT Evaluation and Management codes: These codes are used for genetic counseling and education provided to an individual by a physician or other qualified health care professional who may report evaluation and management services.

10. Examples

Here are 10 detailed examples of CPT code 96040 procedures:

1. A patient with a family history of breast cancer seeks genetic counseling to understand her risk and potential management options.
2. A couple planning to have a child consults with a genetic counselor to discuss potential genetic risks to their unborn child due to a family history of cystic fibrosis.
3. A patient diagnosed with a genetic condition seeks counseling to better understand the implications of the diagnosis and potential treatment options.
4. A pregnant woman with a family history of Down syndrome consults with a genetic counselor to discuss prenatal testing options and potential outcomes.
5. A patient with a family history of Huntington’s disease seeks genetic counseling to understand their risk of developing the condition and potential management strategies.
6. A couple who are carriers of the sickle cell trait consult with a genetic counselor to discuss the risk of their child inheriting the condition and potential management options.
7. A patient with a family history of early-onset Alzheimer’s disease seeks genetic counseling to understand their risk and potential preventative measures.
8. A couple with a history of multiple miscarriages consults with a genetic counselor to discuss potential genetic factors and management options.
9. A patient with a family history of hereditary hemochromatosis seeks genetic counseling to understand their risk of developing the condition and potential treatment options.
10. A couple planning to have a child consults with a genetic counselor to discuss potential genetic risks due to advanced maternal age.