Genetic testing continues to be one of the fastest-evolving areas in healthcare, with reimbursement policies and coding systems adapting rapidly to keep pace. In 2025, the American Medical Association (AMA) introduced significant CPT® code updates that impact how genetic and molecular tests are billed. Staying current is essential to optimize reimbursement and avoid costly errors.
Below is a concise overview of the major changes and smart billing strategies to succeed in the updated environment.
1. Revised Genomic Sequencing Procedure (GSP) Codes: Panel codes associated with hereditary cancers, such as 81432, 81435, and 8143,7, now charge one flat fee that covers both sequencing and deletion/duplication analysis. Previously available add-on codes for CNV (copy number variant) detection have been eliminated. This increase in coding simplicity achieves comprehensive encapsulation of testing within a unitary code.
2. Pharmacogenomic Testing Clarifications: Billing of pharmacogenomic panels testing for more than 6 drug metabolism genes (81418) is simplified. However, Medicare still mandates that the genes tested be specifically listed on the claims, which limits billing transparency.
3. New Molecular Diagnostics Codes: Current technologies, such as optical genome mapping, now carry their code, 81195, for hematologic malignancies. Emerging Tier 2 molecular pathology codes have been issued for new and emerging biomarkers.
4. Expanded Multianalyte Assays with Algorithmic Analyses (MAAA): New MAAA codes like 81515 (for bacterial vaginosis panel) and 81558 (for kidney transplant monitoring) reflect the growing role of algorithm-based genetic interpretation.
Panel vs. Component Coding: Use a comprehensive panel code whenever it accurately reflects the services done instead of billing them by individual gene tests, as in the case where a comprehensive panel is performed. This is compliant, and it often results in higher, cleaner reimbursement.
Proper Modifier Usage: Modifiers -59, distinct procedural service, and -91, repeat test, are vital in capturing proper payment for multiple tests performed on the same day. Append modifier QW for CLIA waived tests.
Accurate Z-Code Matching: For jurisdictions under Medicare MolDX, it is important to ensure that the CPT codes and Z-codes (unique identifiers for laboratory tests) are paired correctly. Denials are commonly caused by a mismatch between the coded tests and the registered tests.
Robust Documentation: All referenced tests must be supported by precise medical necessity documentation, which includes proper linkage to a diagnosis, family history when applicable, methodology of testing, and the anticipated clinical outcome.
Advanced Revenue Optimization Tips
• Authorization and coverage verification: Particularly challenging for commercial payers who manage approval of genetic tests to a high degree.
• Appeals: Strong clinical arguments and fierce resolve can turn around a significant number of denials for genetic testing.
• Predictive Analytics: Using internal claims data, laboratories are able to identify proactively high-risk payers or test types and improve denial management processes.
Payer-Specific Considerations
• Medicare: Compliance with LCDs, including appropriate use of Z-coding, is stringent and non-negotiable. No prior authorization is usually required by Medicare; however, they frequently audit for medical necessity.
• Commercial Insurers: Policies diverge widely. Common hurdles include prior authorization, participation in preferred lab networks and geo-limited coverage for specific genes or panels.
Key Take Away
Within the context of evolving genetic testing technologies lies the reimbursement puzzle. Staying on top of annual CPT code modifications, implementing appropriate billing practices and predictive payer calibration go a long way in achieving favorable payment outcomes.
At Revantage Healthcare, we focus on genetic testing billing, making sure that laboratories and providers can expertly manage these ever-changing requirements — allowing them to concentrate on providing remarkable patient care.
