Reimbursement for genetic counseling and related services. J. Dungan, C. Yates, A. Trivedi, T. Bamlett Sherman, L. Shulman Dept OB/GYN, Northwestern Univ Sch of Med, Chicago, IL.
Introduction: The AMA CPT Editorial Board and CMS recently introduced a new CPT code (96040) to cover genetic counseling (GC) visits provided by counselors only. Previously, GC-related consultations were billed as Evaluation & Management (E&M) visits that necessitated presence of a physician to qualify for payment from most third-party payors. We sought to determine to what extent counselor-only visits at our center billed with this new CPT code have been reimbursed.
Methods: We reviewed the billing statements and account information from patients who presented to our center seeking GC or related consultations during the months of January-March 2007. Services were provided by counselors and/or physicians in the Division of Reproductive Genetics, and include prenatal diagnosis and screening, as well as consultations for hereditary gynecologic cancer families. We categorized visits by CPT code and calculated the mean reimbursement for each code. Only CPT codes used on more than 5 occasions were evaluated.
Results: During the interval reviewed, we billed for 372 visits using CPT code 96040. From this group, excluding those visits still awaiting payment, third-party insurers did not cover any portion of the charges for 3.2% (12/372). Average reimbursement for 96040 was $53.87. In the small number of instances where multiple submissions of 96040 were made because of a prolonged GC visit, payment for each submission was the same. Mean reimbursement for other E&M services were: 99211-$17.25, 99212-$31.57, 99213-$61.00, 99214-$101.65, 99202-$59.96, 99241-$67.79, 99242-$113.17, 99243-$146.25, $99244-$243.68, 99245-$249.38.
Conclusions: Most private insurance carriers are paying for GC-only visits at our center. Although these visits do not require physician presence, reimbursement for physician-attended E&M consultations is much higher for a comparable period of time. Individual centers will need to determine what approach to provision of GC services will best suit their own circumstances, and what personnel are needed to deliver those services.