How To Use CPT Code 81551

CPT 81551 describes the oncology test for promoter methylation profiling of three genes in prostate cancer using formalin-fixed paraffin-embedded tissue. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 81551?

CPT 81551 can be used to describe the oncology test that analyzes the promoter methylation of three specific genes (GSTP1, APC, RASSF1) in prostate cancer. This test utilizes formalin-fixed paraffin-embedded tissue and provides an algorithmic analysis that reports the likelihood of detecting prostate cancer on repeat biopsy.

2. Official Description

The official description of CPT code 81551 is: ‘Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy.’

3. Procedure

1. The lab analyst performs the technical lab test involving promoter methylation analysis of three genes (GSTP1, APC, RASSF1) using formalin-fixed paraffin-embedded tissue.
2. The lab analyst carries out an algorithmic analysis using patient data and the lab test results for patients who have had a negative prostate biopsy.
3. The algorithmic analysis produces a score indicating the likelihood of finding prostate cancer on repeat biopsy.

4. Qualifying circumstances

CPT 81551 is used for patients who have had a negative prostate biopsy and need further evaluation. This test helps clinicians decide whether or when to perform a repeat prostate biopsy. It can aid in avoiding unnecessary repeat biopsies for cancer-free men and prevent missing cancer detection in men with a false-negative biopsy.

5. When to use CPT code 81551

CPT code 81551 should be used when a patient has had a negative prostate biopsy and further evaluation is needed. It is specifically designed to assess the likelihood of detecting prostate cancer on repeat biopsy. This code should not be used for initial prostate cancer diagnosis or for patients who have not undergone a previous biopsy.

6. Documentation requirements

To support a claim for CPT 81551, the following documentation is required:

• Patient information, including relevant clinical history and previous biopsy results
• Details of the technical lab test performed, including the specific genes analyzed (GSTP1, APC, RASSF1)
• Results of the algorithmic analysis and the reported likelihood of prostate cancer detection on repeat biopsy

7. Billing guidelines

When billing for CPT 81551, ensure that the test is performed using formalin-fixed paraffin-embedded tissue and involves the analysis of the specified genes. It is important to follow the specific guidelines and requirements set by the payer. Additionally, do not report CPT 81551 if there are other codes (CPT 81490-81599) already performed in the previous seven days.

8. Historical information

CPT 81551 was added to the Current Procedural Terminology system on January 1, 2018. There have been no updates to the code since its addition.

9. Examples

1. A patient who had a negative prostate biopsy undergoes CPT 81551 to assess the likelihood of detecting prostate cancer on repeat biopsy.
2. After a negative biopsy, a urologist orders CPT 81551 to determine if a repeat biopsy is necessary for a patient with suspicious clinical findings.
3. A patient with a family history of prostate cancer undergoes CPT 81551 to evaluate the risk of developing the disease.
4. Following a negative biopsy, CPT 81551 is performed on a patient with persistently elevated prostate-specific antigen (PSA) levels to assess the likelihood of prostate cancer.
5. A patient with a previous negative biopsy and persistent symptoms undergoes CPT 81551 to aid in the decision-making process for further diagnostic procedures.
6. After a negative biopsy, CPT 81551 is performed on a patient with an abnormal digital rectal examination (DRE) to evaluate the likelihood of prostate cancer.
7. A patient with a previous negative biopsy and rising PSA levels undergoes CPT 81551 to assess the risk of prostate cancer.
8. Following a negative biopsy, CPT 81551 is performed on a patient with a suspicious lesion on imaging to determine the likelihood of prostate cancer.
9. A patient with a previous negative biopsy and a family history of aggressive prostate cancer undergoes CPT 81551 to assess the risk of developing the disease.
10. After a negative biopsy, CPT 81551 is performed on a patient with persistent urinary symptoms to evaluate the likelihood of prostate cancer.