Pathology/Lab Coding Alert

Make sure you change from the ‘old way’ to the ‘new way,’ or lose pay.

If your lab performs molecular testing for BRCA1 and/or BRCA2 gene mutations, you’re facing a major code overhaul for reporting those tests in 2019.

Between the three code families — for BRCA1 mutations, BRCA 2 mutations, or for combination tests interrogating both genes — CPT^® 2019 boasts three code deletions, five code additions, and five code revisions, plus a host of new text notes to guide your coding.

Value: The new gene analysis codes describe testing that may provide physicians with vital information about the patient’s prognosis, and assist in determining whether certain types of treatment could be considered useful, according to Kristen Taylor, CHC, CPC, Associate Partner for Pinnacle Enterprise Risk Consulting Services.

Read on to learn how to report BRCA1 and/or BRCA2 tests in the face of CPT^® 2019’s changes.

Manage Combined BRCA1/BRCA2 Code Refit

You can wave goodbye to 81211 and 81213 as of January 1. These codes are among the CPT^® 2019 deletions, but you’ll also find added and revised codes in this section. The updated code family means that you’ll need to get more specific when reporting BRCA1/BRCA2 combination tests the lab performs.

Here’s how the code family for combination BRCA1/BRCA 2 gene analysis changes for 2019 (underline shows new language, including new codes 81163 and 81164; strike through shows deleted language, including deleted codes 81211 and 81213):

• 81211 (BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb))
• 81162 (BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements))
• 81163 (… full sequence analysis)
• 81164 (… full duplication/deletion analysis (ie, detection of large gene rearrangements))
• 81212 (…; 185delAG, 5385insC, 6174delT variants)
• 81213 (BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants).

This updated BRCA1/BRCA2 code family streamlines your choices for full gene sequence plus duplication/deletion on the same date (81162), full gene sequence alone (81163), and duplication/deletion alone (81164).

A new text note prohibits billing 81162 with components 81163, 81164, as well as component codes from the BRCA1 family (81165, 81166) and the BRCA 2 family (81167, 81216, 81217), plus code 81432 (Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 10 genes, always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53). You’ll find similar bundling restrictions for 81163 and 81164 in the following notes:

• Do not report 81163 in conjunction with 81162, 81164, 81165, 81216, 81432.
• Do not report 81164 in conjunction with 81162, 81163, 81166, 81167, 81217.

Old way: Under the 2018 family, you had a specific code to report testing for common duplication/deletion variants, but that option goes away in 2019.

New way: Instead, a 2019 text note states, “For analysis of common duplication/deletion variant(s) in BRCA [ie exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1k], use 81479.”

“You still have code 81212 for 185delAG, 5385insC, 6174delT variants, but CPT^® 2019 revises the code to update the gene names from ‘breast cancer 1’ and ‘breast cancer 2’ to ‘BRCA1, DNA repair associated’ and ‘BRCA2, DNA repair associated,’” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Focus BRCA1 Test Codes

CPT^® 2019 deletes 81214 (BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)) and adds two new codes to complete the code family for BRCA1 molecular testing, as follows (underline shows new language, including new codes 81165 and 81166):

• 81165 (BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis)
• 81166 (… full duplication/deletion analysis (ie, detection of large gene rearrangements))
• 81215 (... known familial variant).

Code 81215 changes to update the name of the BRCA 1 gene from “breast cancer 1” to the currently preferred nomenclature, “BRCA1, DNA repair associated.”

Old way: Prior to the 2019 code update, you would have reported 81214 for BRCA 1 full sequence analysis and common duplication/deletion variants.

New way: A 2019 text note directs you to turn to new codes 81165 and 81166 when you would have used deleted code 81214 in the past. Another text note directs you to 81479 if the lab interrogates only common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) that 81214 included.

Similar to restrictions in the combined code family, new text notes bundle the new codes with components, as follows:

• Do not report 81165 in conjunction with 81162, 81163, 81432.
• Do not report 81166 in conjunction with 81162, 81164.

Don’t Miss BRCA2 Code Changes

For BRCA2 testing, CPT^® 2019 revises 81216 and 81217 to update the gene nomenclature, and adds 81167 as follows (underline shows new language, including new code 81167; strike through shows deleted language):

• 81216 (BRCA2 (BRCA2, DNA repair associated) (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis)
• 81167 (… full duplication/deletion analysis (ie, detection of large gene rearrangements)
• 81217 (… known familial variant).

Old way: With no specific code for BRCA2 full duplication/deletion analysis, your lab might have been reporting the test using unlisted code 81479.

New way: When the ordering physician requests full duplication/deletion BRCA2 gene analysis test, such as cases when the patient’s mother had ovarian cancer, you would now report new code 81167.

Like restrictions in the other code families, new text notes bundle the codes with components, as follows:

• Do not report 81216 in conjunction with 81162, 81163, 81432.
• Do not report 81167 in conjunction with 81162, 81164, 81217.
• Do not report 81217 in conjunction with 81162, 81164, 81167.