CPT Code 81420 Description, Guidelines, Reimbursement, Modifiers & Examples (2002)

CPT code 81420 Genomic Sequence Analysis Panel analyzes chromosomes 13, 18, and 21 in maternal blood to diagnose fetal chromosomal aneuploidy. Health insurance may cover specific codes while denying reimbursement for others, and certain testing laboratories may use a la carte coding.

Summary

This code may use for the procedures like Genomic sequence analysis, cell-free fetal DNA in maternal blood, and microdeletions in fetal chromosomes. In addition, the code may use for aneuploidy (trisomies 21, 18, and 13) DNA sequencing investigation of particular sites utilizing maternal plasma, with the method provided as a risk score for each trisomy 81507.

81479 is an unlisted method of molecular pathology.

Genomic sequencing of chromosome 21 using cell-free fetal DNA circulating in maternal blood to confirm twin zygosity. The risk score for each trisomy is determined by analyzing specific parts of the fetal genome (trisomies 21, 18, and 13) with maternal plasma, without regard to the proportion of the fetus.

The American Medical Association (AMA) maintains a medical procedure code called Genomic Sequencing Procedures and Other Molecular Multianalyte Assays (MAA). In maternal blood, genomic sequencing may examine the DNA sequences of at least three genes on chromosomes 13, 18, and 21, which may connect to fetal chromosomal aneuploidy.

TIP: You can find all the CPT codes for genomic sequencing procedures here.

Start a no-risk codification test to learn about clinical responsibilities and terminology. If the health plan’s coverage for NIPT testing or cell-free DNA screening for persons of average risk doesn’t yet update, a prior authorization denial may need to challenge. 

Using the letter’s language as a guide, decide whether the NIPT ordered for the relevant patient is medically essential. Individual information, such as contact information, patient or clinical information, and payment information, can be entered at various places throughout the letter.

 Each situation necessitates a unique set of denial justifications. Include copies of the prior authorization denial letter that the patient may have received directly from you and any notifications or explanations of benefits in your letter. Documentation proving clinical relevance or medical need is required. 

CPT Code 81420 Description

The Health Plan makes no guarantees or assurances regarding the quality or completeness of any outside data consulted or used in establishing this clinical policy. This clinical policy complied with accepted medical standards when it may implement. 

The phrase “health plan” refers to an organization that has approved this clinical policy, such as Centene Management Company, LLC, or one of its affiliates. A gene panel is not the same as a group of individual genes. Medicare will only fund operations that are both medically necessary and reasonable.

 As a result, whenever a provider or supplier files a claim, it must be demonstrated that the panel was medically necessary and acceptable. Suppose a service or supplier charges for specific genes, the patient’s medical record may prove that each gene is appropriate and critical from a medical standpoint. 

Multiple genes can test at the same time. When two genes try in parallel for the same indication, the results of one assay have no bearing on whether or not the second gene assay may be complete.

As a result, when the results of one or more gene analyses influence whether or not additional studies are medically acceptable and required, genes evaluated on the same service date are regarded to be assayed serially.

A claim may submit for each unique gene evaluated by a lab. If the laboratory uses NGS testing, a patient’s two (2) or more NGS-assayed genes will regard as part of the same panel, according to NCCI guidelines Chapter 10, Section F, number 8.

Whether the treating practitioner orders a panel of genes or a single gene, the patient’s medical record must show that the therapy was reasonable and necessary.

CPT Code 81420 Billing Guidelines

The CMS payment policy does not permit multiple payments for different testing procedures for the same analyte. Therefore, no provider or supplier expects to bill for more than one (1) unique laboratory genetic testing procedure on a single patient during a single service day. 

When testing may not perform, Cystic Fibrosis (CF) carriers must have a focused test for common variations (CPT code 81220). If testing may not be complete, SMA carrier screening using SMN1 gene dosage analysis is medically essential. 

Medically necessary genetic testing for the same patient on the same service date may necessitate applying a 59 modifier, which states that each successive treatment may report as a new procedure.

Clinical tests may perform on people with no symptoms or evidence of illness. These tests may also conduct without any convincing indication of a diagnosis. It is not appropriate to charge Medicare for non-covered services in the same way that covered services may appropriately set.

Use the proper modifier when invoicing for non-covered services.

It determines by the gene(s) under investigation. Gene variant names may use in the coding for gene-variation assays. All of the above variations may investigate, but these lists are not exhaustive. Additional gene variants need not be published if they will examine as part of the same gene research.

Unless the CPT code specifies that the entire gene sequence should be submitted, whole gene sequencing may not report using CPT codes that test for gene variations.

Tier 1 codes may frequently use to test for the presence of HLA loci or specific genes.

Tier 2 molecular pathology procedure codes (CPT code 81420 – 81408) may use for operations that will not cover by Tier 1 codes (81161, CPT code 81420 – 81383). 

Tier 2 treatments include molecular pathology and rare diseases, while Tier 1 treatments are more prevalent. Therefore, utilizing these codes is usually not a good idea unless specifically encouraged in other coding and billing articles.

CPT Code 81420 Modifiers

If the necessary conditions w met, this modifier may use surgical, medical, or radiological codes. Only the initial code may report while charging. Please note the code as it may amend in subsequent lines.

Sometimes, it may require specifying that a method or service is unique from or unrelated to other E/M services conducted on the same day. 

The modifier 59 may identify processes and services that are not generally documented concurrently with E/M services but are appropriate in the specific context.

For example, if a new procedure, operation, or surgery is conducted on the same day by the same person, the record will keep. 

Unless no other recognized modifiers are available, it is preferable to avoid applying modification 59. Only in the lack of a better modifier should Modifier 59 be used, as it most correctly depicts the situation.

When the 59 modifiers may utilize, a signal that unique procedural services may provide rather than by a panel may lead to an inquiry for medical records. For example, a medical examination may be required if the 59 change may frequently use.

GSP assays ( Genetic Sequencing Profile) that use genes that appear in several code descriptions necessitate the most specific test for the primary condition sought, rather than many codes for one gene (s).

Therefore, the claim will reject or denied if several principles for the same gene are submitted.

They are incorporating proprietary laboratory tests, multianalyte assays (MAAAs), and computational analytics (PLA). Individual component procedures that serve as inputs to MAAAs may report using CPT-compliant reporting, but these assays may not report separately using extra CPT codes. The rule is to refuse or deny claims, including this data.

CPT code stacking has not been removed or reduced due to the 2013 changes to CPT codes. Many CPT codes have shown an increase in molecular pathology and genetic testing use over the last two years. Tier 2 (81403-81408) and Not Otherwise Classified (81479) codes have the most problems invoicing multiple CPT codes for the same test.

However, coding concerns affect other molecular pathology coding categories. 

Title 42 of the United States Code (USC) requires healthcare providers to “offer affordable healthcare services only when necessary.” Therefore, claims that may incorrectly bill using stacking or unbundling services shall be rejected or refused following Section 1320c-5(a) of Title 42 of the United States Code.

These tests, which are generally not required for a Medicare beneficiary, are denied for diseases or conditions that cause premature death (such as Canavan disease) or present with severe signs and symptoms in neonates and young children.

Because they are not relevant to a Medicare beneficiary, are not deemed Medicare benefits (statutorily excluded), and so on, the following types of tests will disallow as Medicare Excluded. Carriers of inherited cancer disorders can diagnose through clinical signs and symptoms that will not explicitly mention in the law.

The modifier used for CPT Code 81420 is 59

CPT Code 81420 Reimbursement

Even though the projected payment for non-invasive prenatal testing (CPT code 81420) may reimburse from $802 to $759, market experts saw this as a positive for NIPT providers such as Illumina and Natera. When the pregnancy is at least ten weeks gestational age, non-invasive prenatal testing (NIPT) to screen for fetal trisomy 13, 18, and 21 (CPT code 81420 and 81507) may consider medically required.

81420 Example

A woman’s blood may test for cell-free fetal DNA after ten weeks of pregnancy. The relative proportion of free fetal DNA present can use to diagnose Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), or Patau syndrome (trisomy 13). The CPT code 81420 will use for this procedure.