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What is Correct Code for Complete Gene Sequencing of PMP22 (peripheral myelin protein 22)?

The Story of a Patient with Neuropathy

Sarah is a 28-year-old woman who has been experiencing weakness and numbness in her feet for several months. She went to see her doctor, Dr. Smith, who suspected she might have Charcot-Marie-Tooth disease (CMT). This condition is often caused by mutations in the PMP22 gene. To confirm his suspicions, Dr. Smith ordered a genetic test.

The Patient's Visit with the Doctor

Dr. Smith: "Sarah, based on your symptoms and family history, I suspect you might have Charcot-Marie-Tooth disease. This is a disorder that affects the peripheral nerves, and it can be caused by mutations in the PMP22 gene. To get a more accurate diagnosis, I'd like to order a genetic test. It involves looking at the entire sequence of the PMP22 gene, which will help determine if you have any genetic abnormalities."

Sarah: "Okay, Dr. Smith. I'm willing to do that. Will this test give me a definitive diagnosis?."

Dr. Smith: "This genetic test should help US get a good picture. We're looking at the entire sequence of the PMP22 gene to get a comprehensive view, not just checking for specific known variants or duplication/deletions. This approach gives US a more accurate analysis of the entire gene."

Medical Coding in Neurology - How to code the complete PMP22 Gene Analysis?

In this scenario, the medical coder would need to use CPT code 81325 to accurately bill for the complete sequencing of the PMP22 gene.

Coding the Genetic Test:

Medical coder: "I see that Dr. Smith has ordered a full gene sequencing test of the PMP22 gene, so we'll need to code this with CPT code 81325. This code specifically describes analyzing the full sequence, rather than looking at specific variants or duplications."

The medical coder understands that this test is comprehensive and analyzes the entire gene sequence to provide a comprehensive analysis of potential genetic abnormalities.

A Tale of Duplicate Lab Work

Another common use case involves situations where a patient might undergo repeated laboratory testing. This happens for a variety of reasons. For example, let's say Dr. Smith wanted to confirm Sarah's results. It would be more common in a different scenario: In some cases, patients might seek second opinions or receive treatment at a different facility. It can happen in case of diagnostic uncertainty. The medical coding must reflect such situations.

Dr. Smith: "Sarah, your genetic testing is now complete. The results indicate that you have a specific mutation in the PMP22 gene consistent with a diagnosis of Charcot-Marie-Tooth disease. Now, I want you to consider getting a second opinion with Dr. Jones at a different facility."

Sarah: "Why? I trust your assessment and I believe you are the best specialist for CMT. I'd prefer not to switch to another specialist."

Dr. Smith: "I appreciate that Sarah, but this is just to ensure all available diagnostic avenues are explored and that we can offer the best possible treatment for your case. Having Dr. Jones look at your test results provides an extra level of certainty. While it may feel like more work, it's in your best interests to ensure the most accurate diagnosis and treatment plan. "

Modifier 91: Coding the Repeat Genetic Test

Medical Coder: "The patient had a PMP22 gene analysis (CPT 81325) at our facility. Now we have an order for another genetic analysis of the PMP22 gene, as part of a second opinion, at a different facility. We will need to add modifier 91 (Repeat Clinical Diagnostic Laboratory Test) to the second coding of CPT 81325."

The medical coder uses modifier 91 because the laboratory tests, although similar, are conducted separately, serving as an independent confirmation, or in case of the same patient receiving different care at another facility. This ensures accurate billing based on the individual tests' significance and need, emphasizing proper code application in the coding process.

Testing on Multiple Tissue Samples

Sometimes, diagnostic testing might involve analyzing multiple samples to confirm a diagnosis.

Scenario: Multiple Tissue Samples

Dr. Smith has received a blood sample for Sarah's initial genetic test. After reviewing Sarah's results and clinical findings, HE might want to further assess with other samples: "To further confirm the diagnosis, we may want to conduct a separate gene analysis on a nerve biopsy, for a complete picture." This helps the doctor compare and analyze DNA variants from different tissues, strengthening the diagnostic confidence.

Applying a Modifier

In such cases, the medical coder should append modifier XS to the code, because the test is performed on different structure:

Medical Coder: "It appears we have an order for another genetic test on the PMP22 gene, but now Dr. Smith has requested a sample from a different structure - a nerve biopsy, to confirm the findings of the previous test from blood. This indicates a "separate structure" service, which will require the use of modifier XS for this second instance of code 81325."

The coder makes sure to use the appropriate modifier (XS in this case) to indicate the distinct nature of the procedure. In these circumstances, the "separate structure" modifier reflects the fact that different parts of the body were used, enabling more robust medical coding that accurately describes the procedure performed, ultimately assisting in accurate billing.

Importance of Using Current CPT Codes

It is important to note that the CPT codes are proprietary codes owned by the American Medical Association (AMA). Medical coders are required to obtain a license from the AMA in order to use these codes. Additionally, the AMA releases updates to the CPT code set every year. These updates are necessary to ensure that coders are using the most up-to-date codes, which may include new codes or modifications to existing codes.

Failure to pay the AMA for the license and use current CPT codes can result in significant legal penalties. You could face civil and criminal charges for violation of copyright law, including fines and imprisonment. Furthermore, incorrect coding practices can lead to inaccurate reimbursement, audits, and other issues.

It is crucial for all medical coding professionals to be familiar with and abide by the rules and regulations surrounding the use of CPT codes. They should always consult the latest CPT code manual from the AMA for accurate information.

Learn how AI can automate medical coding with this detailed guide. Discover the CPT code for complete gene sequencing of PMP22, the importance of modifiers like 91 and XS, and how AI can help prevent coding errors and ensure compliance.

What CPT Code is Used for Complete Gene Sequencing of PMP22?