Billing and Reimbursement
Indications
DNA-based testing for blood group antigens is assigned a CPT code-81403 (a Tier 2 code). This code is for molecular pathology procedure, Level 4 (for example, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons). For an extended antigen profile (HEA) or RHD genotype, or human platelet antigens (HPA), code 81403 should be used. In order to receive reimbursement for the service, healthcare providers must demonstrate that it is a medically necessary test for that particular patient and insurance pre-authorization may be required. The Medicare coverage for DNA-based testing is determined by the local Medicare Administrative Contractor (MAC). One Mac, Palmetto GBA, finalized a local coverage determination (LCD) for the human erythrocyte antigen (HEA) test through its Molecular Diagnostic Services (MoIDX) program. Under the LCD, Medicare will currently cover pre-transfusion testing for the following categories of patients in their jurisdiction:
- Long-term, frequent transfusions anticipated to prevent the development of alloantibodies (e.g., sickle cell anemia, thalassemia, or other reason);
- Autoantibodies or serologic reactivity that impedes the exclusion of clinically significant alloantibodies (e.g., autoimmune hemolytic anemia, warm autoantibodies, recent transfusion, positive DAT, high-titer low avidity antibodies, other reactivity of no apparent cause)
- Suspected antibody against an antigen for which typing sera is not available; and
- Laboratory discrepancies on serologic typing (e.g., rare RhD antigen variants).
Reimbursement
Most hospitals receive bundle payments for inpatient visits, and hence reimbursement fees would not be applicable in this setting. However, in the outpatient setting, if the healthcare provider proves medical necessity, the CPT code 81403 may be billed.
Physician Fees for Interpretation
CMS created a HCPCS G-code, G0452 (molecular pathology procedure; physician interpretation and report). In connection with the 2014 Medicare Physician Fee Schedule (PFS), CMS assigned a work relative value unit (RVU) of 0.37 for molecular pathology interpretation (G0452). The current Medicare reimbursement for the professional interpretation is approximately $19 (www.cms.gov/apps/physician-fee-schedule).