There is an NCCI edit on these codes with 81455 being the column 1 code and 81456 as column 2. You can bypass it with a modifier, but my question is why would you need to do 81456 indicates it is an RNA analysis and 81455 is DNA analysis or combined DNA & RNA analysis? I have a feeling that this is something you are likely to see edits on, even if billed with a modifier, and you will likely need to appeal any denials to show the medical necessity of performing both tests on the same DOS.
Since 81455 can include the RNA analysis that is represented by 81456, I'm having a hard time understanding why in general you would be billing both of the procedures on the same DOS. I work for an insurance company, and this is a red flag for my inner auditor, and it would be something I'd suggest we monitor if we were seeing these codes billed together regularly with a modifier trying to bypass the edit.
So according to R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas.
Background: The original codes 81445, 81450, and 81455 included only DNA analysis. With the advent of new lab test methods, some labs began adding RNA analysis, and CPT® revised the codes to add “and RNA analysis when performed” to the code descriptors.
Now: Because labs may now perform DNA and RNA analysis in a single procedure, or may perform one or the other or both as distinct procedures, CPT® revised the codes yet
again. The revised codes 81445, 81450, and 81455 are now parent codes and include other minor revisions such as correcting alphabetical order of the listed genes.
Plus: By adding three new “child” codes (81449, 81451, 81456), you now have a way to separately report a stand-alone RNA test, explained Jan A. Nowak MD, PhD, FCAP, representing The College of American Pathologists in his presentation at the Clinical Laboratory Fee Schedule (CLFS) annual meeting for the new CPT® 2023 codes.
Guidelines: The GSP introduction section and text notes following codes 81445-81456 explains how you should report DNA and/or RNA testing for somatic alterations in neoplasms:
• If the lab uses a combined method (one procedure) for both DNA and RNA analysis, you should report one of the parent codes.
• If the lab performs only DNA testing, report one of the parent codes.
• “For targeted genomic sequence DNA analysis and RNA analysis performed separately rather than via a combined method, report 81445, 81450, or 81455 for the DNA analysis and report 81449, 81451, or 81456 for the RNA analysis,” according to new language in the introduction and a new text note following these codes.
• If the lab performs just RNA testing, report one of the child codes.
So, if we are running two separate test DNA and RNA and it is being reported out separately then 81455 and 81456 should be appropriate correct?
Thank You