Genetic Counselors
The Coding Committee recently received a question regarding how to bill for Genetic Counselors within the MFM practice. The Committee felt this was an opportune time to review coding & billing practices in this scenario.
Coding for Genetic Counselors is not uniform across states and healthcare plans. This is partly because Genetic Counselors are not currently recognized as health care providers as defined by Medicare/CMS. Additionally, licensing for genetic counselors is not available in all states. For this reason, coding practices can be obscure and confusing as they vary due to:
- Contracts with different payers.
- Credentialing with the payers in a group of providers or individually.
- Services provided under supervision as “incident to” or individually.
- Services provided in different places of service – hospital, outpatient facility, and doctor's office.
Let’s start with discussing regulatory concerns at the Federal level.
CMS
In 2021, during the COVID pandemic the importance of ancillary health care personnel was recognized and a new bill was introduced in Congress - House Bill H.R. 2144 (Access to Genetic Counselor Services Act of 2021) aims to expand access to Genetic Counseling while driving down healthcare costs by reducing the overall costs of genetic services: https://www.policymed.com/2021/04/new-house-bill-aims-to-expand-access-to-genetic-counseling-drive-down-healthcare-costs.html. The bill was developed with the help of the National Society of Genetic Counselors. If passed, the bills would authorize the Centers for Medicare and Medicaid Services (CMS) to recognize certified Genetic Counselors as healthcare providers, giving beneficiaries improved access to the services Genetic Counselors provide. Currently, Genetic Counselors must provide services under direct supervision, which means they are only available to beneficiaries when they are being supervised by a Medicare-certified healthcare provider (physician or nurse practitioner). H.R. 2144 would allow Genetic Counselors to bill Medicare directly and be reimbursed for their services at 85 percent of physician billing. Work on this bill is ongoing.
STATES
Each State has its own regulations regarding Genetic Counselors licensing. This information can be found here : https://www.nsgc.org/Policy-Research-and-Publications/State-Licensure-for-Genetic-Counselors/States-Issuing-Licenses
In addition to the Federal and State regulatory concerns, individual payers also have specific limits with the use of genetic counseling CPTs that prompt denials when submitted for reimbursement.
PAYERS
The appropriate CPT code for Genetic counseling services is 96040. However, some payers do NOT accept the 96040 and instead require these visits be billed utilizing outpatient E/M coding (99202 – 99215). In addition, to make things more challenging, some do not recognize Genetic Counselors' services at all. This poses a challenge as in order to bill outpatient E/M codes you must have an NPI and be recognized by CMS as a provider. Following are three examples of how different payers consider Genetic Counselors' services:
Aetna – accepts 96040
http://www.aetna.com/cpb/medical/data/100_199/0189.html
Cigna – accepts 96040
Tricare (follows Medicare rules) – DOES NOT accept 96040:
“Genetic counseling is a covered benefit when billed as an Evaluation and Management (E&M) code. Medical genetics and genetic counseling billed with CPT 96040 are not covered under the TRICARE program”.
Let’s review some clinical examples to further explain this unique coding situation.
CPT 96040
We can consider a case when Genetic Counselors' services are billed under group NPI for MFM practice. It is important to know if your Genetic Counselor is billing CPT code 96040, which is specific to use by Genetic Counselors. MFM providers can NOT use 96040.
Genetic Counselor is billing 96040
Genetic Counselors services are distinct from MFM services and would not establish the patient with regards to E/M billing (99202-99215). The patient would be a new patient visit for the MFM who follows the GC session regardless of prior 96040 billing.
Genetic Counselor is not billing 96040
If a Genetic Counselor cannot use 96040 due to licensing, contract, or credentialing issue, then they can bill for new patient E&M codes 99202-99205.
E/M Codes 99202-99205 can be billed if the Genetic Counselor is considered an NPP (Non-Physician Practitioner) by a specific payor and in that state and working under physician’s supervision, otherwise they can bill only 99211.
If E&M code 99202-99205 has been billed by Genetic Counselor, then it would cause denial of E&M service provided by MFM on the same day because outpatient E&M CPT codes cannot be billed twice under the same NPI/tax ID. If MFM in this scenario provides E&M service on the following day, it should be billed for established patient 99212-99215 or 99241-99245 (if consult codes are recognized by the payer).
In sum, coding and reimbursement for genetic counseling services is challenging and complex. It is highly recommended to contact individual payors regarding their credentialing, contracting, billing, and coding requirements for Genetic Counselors.