Description

This policy addresses genetic and molecular testing services and applies to codes billed from the following sections in the CPT/HCPCS Manual:

• Molecular Pathology
• Genomic Sequencing Procedures and Other Molecular Multianalyte Assays (GSP)
• Multianalyte Assays with Algorithmic Analyses (MAAA)
• Proprietary Lab Analysis (PLA)

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) allows reimbursement for genetic testing, in accordance with the guidelines outlined below. 

Reimbursement Guidelines

All providers billing for genetic and molecular testing services must bill according to the following requirements (or services may be denied):

• Bill for the test performed as indicated on the test requisition form and delivered on the test result
• Include ordering provider information on all claim transactions or the services may be denied
• Coding must be consistent with AMA coding guidelines:
  • Codes are determined based on the attributes of the testing performed, not based on the clinical indication of the member
  • If a test qualifies for panel code(s), the panel code(s) must be used.  Per the NCCI Manual, Chapter 10, Section F-8, if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure 
  • If a panel code is not appropriate (or when medical policy exclusively covers components of panels), a limited number of individual components from multi-gene tests may be billed
  • Only one unit of the miscellaneous, non-specific code 81479 may be billed per test.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive.  For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Bundling Guidelines

NCCI Editing

Once in a Lifetime

Pricing and Adjudication Principles

References

American Medical Association, Current Procedural Terminology (CPT^®) and associated publications and services

CMS NCCI Policy Manual

History

8/01/2025 New policy developed.  Notification on 6/01/2025 for effective date 8/01/2025. (ss)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.