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United Healthcare Reimbursement Policy Update for Molecular Pathology

  • Customer Account Manager, XiFin

United Healthcare announced that the effective date of their reimbursement policy update for molecular pathology has moved from dates of service beginning September 1, 2019, to dates of service beginning November 1, 2019.

This reimbursement policy change affects claims submitted with codes for Tier 1 and Tier 2 Molecular Pathology. Tier 2 Molecular Pathology codes are 81400 – 81408, and are to be used when there is no Tier 1 code for the service that was performed. These codes are assigned by the American Medical Association (AMA) and indicate the level of effort associated with the service performed. If neither a Tier 1 nor a Tier 2 code is assigned for a service, an unlisted code, such as 81479 can be used.

The AMA guidance also provides claim designation codes in the molecular pathology gene table that represent specific genes that are being tested. UnitedHealthcare will require providers to append the AMA claim designation to identify the specific gene when submitting a Tier 2 Molecular Pathology code. If there is not a claim designation assigned, the provider should submit the abbreviated gene name. This information can be found in the CPT Molecular Pathology Gene Table or the specific analyte is listed after each Tier 2 code descriptor.

In every case, the most specific code available must be used. For example, when multiple gene procedures (considered a panel) are provided, a proprietary laboratory analysis (PLA) code would take precedence. If no approved PLA code is applicable, then a Tier 1 or Tier 2 Molecular Pathology code, such as a genomic sequencing procedure (GSP) code would be applied. If a Tier 1 code exists for the procedure, it must be submitted with a Tier 1 code, a Tier 2 code is not accepted. Only if no other code describes the services can an unlisted code, such as 81479 be used.

An unlisted code, such as 81479 can only be used once per patient, per specimen, and date of service. If billed on the same date of service, per member, as a PLA or GSP, the PLA or GSP will take precedence, as only one is allowed to be billed per day.

When billing with an unlisted code, such as 81479, the test must be registered with the National Institute of Health (NIH) Genetic Testing Registry.

The most specific CPT code available must be input in the billing code field. Only one code is now allowed in the billing code field. If an unlisted code, such as 81479 is used in the billing code field, the NIH Genetic Testing Registry (GTR) code must be placed in the test name synonym field. In addition:

  • The condition/disorder tested data must be placed in the test name or long test description field
  • The specimen type must be included in the long test description field
  • The details of the CPT codes must be included in the long test description field
  • The AMA claim designation code and the GTR unique test ID should be reported in Loop 2400 or SV101-7 field for electronic claims and in Box 24 for paper claims.

If these new reimbursement rules are not followed correctly, United Healthcare may deny the claim. Claims that have complied with notification or prior authorization requirements in UnitedHealthcare’s genetic testing and molecular prior authorization program satisfy the policy’s requirements without further provider action if they meet UnitedHealthcare’s genetic test lab registry requirements.

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Published by XiFin
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