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Q: We are desperately needing your help in the molecular coding for BCR/ABL major/minor. We send the sample to Quest with test code 91065, and then they perform different testing depending on whether the test was performed previously. There are different charges and CPT codes billed depending on what is reported.
Our question is can we bill more than CPT 81206 (major) and CPT 81207 (minor)? Can we also bill CPT 81401 for the RNA extract?
A: Excellent question! The introduction of the new "molecular pathology" procedure codes has definitely caused confusion when it comes to charge capture. If I understand correctly, you send Quest test code 91065 BCR-ABL1 Gene Rearrangement, Quantitative, PCR. According to Quest's online test menu, they will base the actual testing performed on the following algorithm:
If P190 transcript expression was previously documented, only P190 BCR-ABL1 will be performed at an additional charge
If P210 transcript expression was previously documented, only P210 BCR-ABL1 will be performed at an additional charge
If no prior positive is documented P190 BCR-ABL1 and P210 BCR-ABL1 will be performed at an additional charge
Based on the information provided above, the CPT codes reporting for billing may vary from patient to patient. It is always tricky when a single orderable test can be associated with different codes for billing based on individual test results, so extra care should be taken when hard coding these types of services into the charge description master ("CDM").
The new CPT codes created in 2012 for reporting BCR/ABL testing are as follows:
81206 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative
81207 minor breakpoint, qualitative or quantitative
81208 other breakpoint, qualitative or quantitative
To translate this into more palatable terms, CPT Assistant (May 2012) provided additional guidance related to BCR/ABL breakpoints. Major breakpoint (CPT 81206) encompasses those exons leading to p210 (i.e. e13a2, e14a2; b2a2). Minor breakpoint (CPT 81207) encompasses p190 (i.e. e1a2). Other breakpoints (CPT 81208) could include p230.
CPT guidelines also state that the molecular pathology codes listed above include all analytical services performed in the test (cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection), so these should not be reported and billed separately. Only those procedures required prior to cell lysis (microdissection, CPTs 88380 and 88381) may be reported separately when performed.
Based on the information provided by Quest, the following coding is recommended:
1. If P190 transcript expression was previously documented, only P190 BCR-ABL1 will be performed at an additional charge
2. If P210 transcript expression was previously documented, only P210 BCR-ABL1 will be performed at an additional charge
3. If no prior positive is documented P190 BCR-ABL1 and P210 BCR-ABL1 will be performed at an additional charge
CPTs: 81206 & 81207
Due to the three potential coding variations, resulting from a single orderable test, I would highly recommend internal testing of any automated charge capture processes to ensure accuracy prior to claim submission. Only the test that was performed and resulted should be billed -- which will vary by patient -- making routine auditing and monitoring of this type of molecular pathology procedure billing a much needed component of a clinical laboratory's compliance plan.
"Melissa Scott is a senior consultant in the Reimbursement & Advisory Services Division of Altegra Health."