Financing and Payment
Coding for Genetic Services
Diagnosis codes are a standardized set of codes used to report diseases and patient conditions. Providers and researchers currently report disease and patient condition information using the International Classification of Diseases, Ninth Revision (ICD-9). The ICD, Tenth Revision (ICD-10) coding system is expected to be implemented in 2014.
There exist significant concerns regarding the appropriate coding in the current system for genetic services by providers. Some common issues experienced include:
- The ICD-9 codes often do not account for all genetic syndromes and conditions;
- Providers often code conditions by symptoms that are exhibited instead of syndromes/specific conditions;
- Providers may need assistance in identifying appropriate codes for genetic conditions that are unspecified/unidentified (chromosomal deletions) or otherwise unknown.
Providers are charged with the obligation to code to the highest specificity possible. The GPCI has developed a Coding Fact Sheet to assist providers with appropriate coding of genetic services. The Time Out for Genetics educational webinar presentation provides additional information about this topic.
Is there a list of ICD-9 codes for genetic patients?
Procedure codes identify medical and diagnostic services rendered by providers. Those codes are typically submitted using the Current Procedural Terminology (CPT) coding system, often referred to as Level I Healthcare Common Procedure Coding System (HCPCS) codes. Procedure codes can be expanded upon using code modifiers to denote additional information.
Providers and laboratories today commonly use a procedure-based approach to identify genetic tests and molecular diagnostics by the steps involved in the test rather than the nature of the test itself. Commonly, multiple procedure codes, or “stacking codes”, are used to represent the various steps involved in performing genetic or molecular tests. Individual procedure codes are given for each type of step to create a “stack” of codes for each test. In some cases, laboratories identify the codes that best represent their own processes for genetic testing services, making variation in code use common. Even when laboratories use the same procedure codes for a test, they may include different services in those procedures, making comparisons — or aggregation of data — across laboratories unfeasible.
Coding ResourcesManual on Reimbursement for Medical Genetics Services
American College of Medical Genetics and Genomics (ACMG) has a textbook available for purchase on an overview of the basics of billing and reimbursement for health care services. The Manual includes clinical genetics, laboratory genetics and genetic counseling services. It is designed to help the Medical Geneticist understand the intricacies of billing and reimbursement, as well as some of the problems and solutions that genetic service providers face in obtaining appropriate reimbursement for their services. It is rich in resource material, important addresses and Web sites.
United Healthcare Children's Foundation
This is a great resource for patients and families who are covered by commercial insurance, but who need help with medical expenses, including genetic tests, not covered by their insurance.
Insurance Coverage Toolkit for Chromosomal Microarray Testing
The International Standards for Cytogenetic Arrays (ISCA) Consortium has created a toolkit containing resources to assist providers in advocating for insurance coverage and reimbursement on CMA tests. You can view these resources and others provided by the ISCA Consortium by registering for a free account.
American Medical Association's CPT Coding, Medical Billing and Insurance Resources
For more resources on coding, please visit AAP Practice Support -- Coding Resources or contact the AAP Coding Hotline at 800/433-9016 extension 4022 or firstname.lastname@example.org.
Tell us what you think! Take this 3-5 minute survey to provide us with your feedback to inform future update to the site.