Molecular Pathology Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

This policy describes the information required when claims are submitted for Molecular Pathology services utilizing Tier 1 and Tier 2 Molecular Pathology codes, Genomic Sequencing Procedures (GSP) and other Molecular Multianalyte Assay codes, Proprietary Laboratory Analysis (PLA) codes and unlisted code 81479.

All services described in this policy may be subject to additional UnitedHealthcare reimbursement policies including, but not limited to, the Clinical Laboratory Improvement Amendments (CLIA) ID Requirement Policy, the Laboratory Services Policy, the Add-On Policy, and the CCI Editing Policy.

Policy Codes

Find your specific codes below.

This policy contains more codes than can be displayed on one screen. Find your specific code below.

Enter your code here As you input 2 or more characters, a clear button becomes available, and codes will dynamically display below. The number of returned codes will decrease as you enter more characters.

  • 0001U
  • 0012U
  • 0013U
  • 0014U
  • 0016U
  • 0017U
  • 0018U
  • 0019U
  • 0022U
  • 0023U
  • 0026U
  • 0027U
  • 0029U
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  • 0031U
  • 0032U
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  • 0036U
  • 0037U
  • 0040U
  • 0045U
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  • 0055U
  • 0056U
  • 0060U
  • 0069U
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  • 0078U
  • 0081U
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  • 0088U
  • 0089U
  • 0090U
  • 0091U
  • 0094U
  • 0101U
  • 0102U
  • 0103U
  • 0111U
  • 0113U
  • 0118U
  • 0129U
  • 0130U
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  • 0134U
  • 0135U
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  • 0138U
  • 0153U
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  • 0156U
  • 0157U
  • 0158U
  • 0159U
  • 0160U
  • 0161U
  • 0162U
  • 81105
  • 81106
  • 81107
  • 81108
  • 81109
  • 81110
  • 81111
  • 81112
  • 81120
  • 81121
  • 81161
  • 81162
  • 81163
  • 81164
  • 81165
  • 81166
  • 81167
  • 81170
  • 81171
  • 81172
  • 81173
  • 81174
  • 81175
  • 81176
  • 81177
  • 81178
  • 81179
  • 81180
  • 81181
  • 81182
  • 81183
  • 81184
  • 81185
  • 81186
  • 81187
  • 81188
  • 81189
  • 81190
  • 81200
  • 81201
  • 81202
  • 81203
  • 81204
  • 81205
  • 81206
  • 81207
  • 81208
  • 81209
  • 81210
  • 81212
  • 81215
  • 81216
  • 81217
  • 81218
  • 81219
  • 81220
  • 81221
  • 81222
  • 81223
  • 81224
  • 81225
  • 81226
  • 81227
  • 81228
  • 81229
  • 81230
  • 81231
  • 81232
  • 81233
  • 81234
  • 81235
  • 81236
  • 81237
  • 81238
  • 81239
  • 81240
  • 81241
  • 81242
  • 81243
  • 81244
  • 81245
  • 81246
  • 81247
  • 81248
  • 81249
  • 81250
  • 81251
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  • 81253
  • 81254
  • 81255
  • 81256
  • 81257
  • 81258
  • 81259
  • 81260
  • 81261
  • 81262
  • 81263
  • 81264
  • 81265
  • 81266
  • 81267
  • 81268
  • 81269
  • 81270
  • 81271
  • 81272
  • 81273
  • 81274
  • 81275
  • 81276
  • 81277
  • 81283
  • 81284
  • 81285
  • 81286
  • 81287
  • 81288
  • 81289
  • 81290
  • 81291
  • 81292
  • 81293
  • 81294
  • 81295
  • 81296
  • 81297
  • 81298
  • 81299
  • 81300
  • 81301
  • 81302
  • 81303
  • 81304
  • 81305
  • 81306
  • 81307
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  • 81309
  • 81310
  • 81311
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  • 81313
  • 81314
  • 81315
  • 81316
  • 81317
  • 81318
  • 81319
  • 81320
  • 81321
  • 81322
  • 81323
  • 81324
  • 81325
  • 81326
  • 81327
  • 81328
  • 81329
  • 81330
  • 81331
  • 81332
  • 81333
  • 81334
  • 81335
  • 81336
  • 81337
  • 81340
  • 81341
  • 81342
  • 81343
  • 81344
  • 81345
  • 81346
  • 81350
  • 81355
  • 81361
  • 81362
  • 81363
  • 81364
  • 81400
  • 81401
  • 81402
  • 81403
  • 81404
  • 81405
  • 81406
  • 81407
  • 81408
  • 81410
  • 81411
  • 81412
  • 81413
  • 81414
  • 81415
  • 81416
  • 81417
  • 81420
  • 81422
  • 81425
  • 81426
  • 81427
  • 81430
  • 81431
  • 81432
  • 81433
  • 81434
  • 81435
  • 81436
  • 81437
  • 81438
  • 81439
  • 81440
  • 81442
  • 81443
  • 81445
  • 81448
  • 81450
  • 81455
  • 81460
  • 81465
  • 81470
  • 81471
* COMM-Molecular-Pathology-Policy.pdf
Click to Download: Molecular Pathology Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans

Questions and Answers

Q: Can I report separate molecular pathology CPT codes in instead of a PLA CPT code?

A: Per the AMA, when a PLA code is available to report a given proprietary laboratory service the service should not be reported with any other CPT code(s) and other CPT code(s) should not be used to report services that may be reported with the specific PLA code.

Q: The testing for HPA1, HPA2, HPA3, and HPA4 was performed to rule out neonatal alloimmune thrombocytopenia. Would it be correct to report CPT codes 81105, 81106, 81107, and 81108 for this testing?

A: No, multiple molecular variants tested on the same date of service are considered a multianalyte panel and requires reporting with a single CPT code. The test panel provided should be reported with the PLA (when applicable for the provider), GSP, or other MAA multiple analyte code. In the absence of an existing code, the panel of tests provided may be registered on the NIH GTR and submitted with the unlisted CPT code 81479.

Q: The testing provided overlapped two different GSP codes. Should I report both GSP codes?

A: Only one GSP CPT code may be reported for the testing provided. The CPT guidelines for use of the GSP codes indicate when a GSP assay includes gene(s) that are listed in more than on code descriptor, the code for the most specific test for the primary disorder sought should be reported.

Q: Laboratory XYZ performed testing that fits the PLA code descriptor; however the PLA test was not marketed to Laboratory XYZ by the proprietary clinical laboratory or manufacturer. May the PLA test code be reported?

A: No, the proprietary clinical laboratory or manufacturer may market the right to use their tests to multiple laboratories. These codes may only be reported by registered proprietary laboratory or laboratories that have the

proprietary relationship with the proprietary clinical laboratory or manufacturer.

Q: When would it be appropriate to report 81479?

A: It would be appropriate in the following scenarios:

  • The single gene or analyte analyzed is not represented by an existing Tier 1 or Tier 2 code. If the analyte is not listed in the Tier 1 descriptor or under one of the Tier 2 codes, 81479 should be used.
  • Multiple gene variants were analyzed in a single test panel and there is not an appropriate PLA, GSP, or other MAA test code to report

Q: When would it be appropriate to report more than one CPT code 81479 on a single date of service?

A: From a CPT coding perspective, code 81479, unlisted molecular pathology procedure, should only be reported once per patient, per specimen and date of service to identify the services provided because it does not identify a specific service. When registering more than one CPT code 81479 on the NIH GTR, the appropriate specimen type may be selected (i.e. amniotic fluid, bone marrow, fresh tissue, saliva, urine, etc.) Each CPT code 81479 reported should be listed on separate claim lines with their respective GTR ID. In addition, if requested, the patient records should support that different specimens were tested.

Q: A test was performed on the anginine vasopressin receptor 2 gene. How should this be reported?

A: Report Tier 2 code 81404 with ZZAVPR2 in field 2400 Sv101-7 on the electronic claim form or in the shaded area of the service line in section 24 on a paper claim form.

Q: How do I register my test in the NIH GTR?

A: Labs can register tests via the GTR submission user interface after they create a MyNCBI credential and a lab record. This may take 2-3 business days. Once a lab has an active lab record, the lab can begin registering tests. Additional information ca be found at: https://www.ncbi.nlm.nih.gov/gtr/docs/submit/

Q: What are the benefits of registering tests in the NIH GTR?

A: In addition to providing information about the current scope of genetic testing technologies, NCBI resources seek to improve access to information about medically important variation.