NEW ORLEANS – Genetic counselors are hopeful a recently unveiled billing code will enable them to more accurately bill for time spent on patient visits and secure better reimbursement, according to comments from speakers and attendees at the annual meeting of the National Society of Genetic Counselors held this week.
The new Current Procedural Terminology (CPT) code, 96041, which goes into effect Jan. 1, 2025, eliminates a face-to-face requirement included in the previous code and will allow gene counselors to bill for time spent on a patient's case outside of an appointment.
"This code is as good as I would have hoped," said Heather Zierhut, the director of the University of Minnesota's genetic counseling graduate program and former NSGC president who started the code modernization effort. She noted, though, that even as genetic counselors celebrate the new code, there will be challenges as they move forward.
The American Medical Association, which owns the codes healthcare providers use to identify and bill for medical services and procedures, first developed a CPT code for genetic counseling in 2005, called 96040, which then went into use in 2007. Under this current code, nonphysician genetic counselors can bill for 16 to 30 minutes of face-to-face services as well as for telegenic services using code modifiers.
But as the code description specified face-to-face services, genetic counselors have been unable to use the 96040 CPT code to bill for other aspects of patient care that might take place before or after a patient is seen, such as reviewing a chart prior to a patient visit, ordering testing, or coordinating with other healthcare providers.
The new 96041 code lacks that requirement. It will allow genetic counselors to bill for any medical genetics and genetic counseling services, including that preparatory or post-appointment work.
"I think it will be really helpful," Jennifer Razak, a genetic counselor who attended the session, said of the new code. She noted that right now a lot of what she does in the clinic isn't captured by the current code.
However, that work must be done on the same day as the patient encounter to be eligible for billing under the new code.
"If you do all of your prep work three days in advance, unfortunately you can't count those minutes," Rachel Bluebond, a genetic counselor at Ambry Genetics and a panel expert for the NSGC CPT code initiative, said during the presentation. "If you don't write your note until the next day, those minutes won't count either."
Bluebond noted, though, that the code has some time "baked in" that accounts for some of these activities on other days, but that the number of units billed for cannot change based on what's done on other days. In the presentation, Brian Reys, a genetic counselor at UT Southwestern and the NSGC adviser to the AMA CPT editorial panel, noted that the value of the new code will be the same as the previous one and that genetic counselors will be able to use more increments of the code.
This focus on day of services, genetic counselors pointed out, may require them to make changes to how they run their clinics, handle their workflow, and keep track of their time. Razak, for instance, noted that she shares her clinic with another genetic counselor, and they typically alternate clinic days, but they may have to shift that arrangement so they have more time to do their documentation the same day.
Still, Bluebond presented an analysis NSGC conducted that shows the code change will benefit the vast majority of genetic counselors in terms of the number of units they can bill.
As part of the society's professional survey, NSGC asked genetic counselors about the amount of time they typically spend with patients and the time they spend on cases before and after that visit. As Reys reported during the session, genetic counselors spent about 75 minutes on pre- and post-visit work for every 30 minutes of interaction time. Bluebond added that at every time interval analyzed, they expected genetic counselors to be able to report more units of time with the new code. For instance, under 96040, genetic counselors who spent about 30 minutes with patients and had a total work time of about 72 minutes would bill for one unit of time, while under the new code, they would bill for two.
Bluebond said that the NSGC survey analysis further suggests that 93.2 percent of genetic counselors would benefit from this change and would be able to bill 1.54 additional time units per consultation on average. For the remaining 6.8 percent, the analysis indicated the change would be neutral and not affect the number of units billed.
Some genetic counselors are concerned about how payors will react to this change. "I am hopeful [about the effects of the CPT code change], but my major concern is: Are the payors going to pay?" Casey Duld, a genetic counselor who attended the session, said.
NSGC has already begun to send letters to large national payors to alert them to this change and will follow up with further outreach, including meetings with the larger payors to make sure they understand the value of genetic counselors. "If somebody is already covering genetic counseling, we're encouraging them to just simply move over to the new code," Bluebond said. "[But] if it's a payor that maybe doesn't understand the value of genetic counselors, we will be using this as a great opportunity to advocate on the behalf of the genetic counseling industry and make sure we are encouraging them to start covering the new code."
The organization is also providing tools for genetic counselors to help notify regional and smaller payors.
The CPT code change initiative comes in parallel to NSGC's push for recognition by the Centers for Medicare and Medicaid Services as healthcare providers, Zierhut said. Without such recognition, genetic counselors cannot bill Medicare even with the new code for reimbursement.
"While we were working on it and chipping away" at CMS recognition, she said, a CPT code change "could help us to take steps forward towards that ultimate goal of better reimbursement for genetic counselors."
As part of the CPT code change process, the code is reviewed by CMS. Reys noted that while the code will be present on the CMS Physician Fee schedule with a valuation, it is still a status B code, which means that CMS is not planning to recognize it.
"We still have a long fight to be recognized by Medicare and Medicaid — that's going to be the real key to getting reimbursement," Duld said. When asked if the new CPT code would help that process, she said, "It can't hurt."