Summary & Overview
CPT 81404: Molecular Genetic Testing for MEN1 and TP53
CPT code 81404 represents a Tier 2 molecular pathology procedure focused on genetic testing for MEN1 and targeted sequence analysis of 2–5 exons of TP53. This code is significant in the national landscape of precision medicine, as it enables clinicians to detect genetic mutations linked to multiple endocrine neoplasia and various forms of leukemia and cancer. The procedure is typically performed in clinical laboratory settings and is essential for informing diagnosis and treatment strategies in oncology and endocrinology.
Major national payers covering this code include Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare. The publication provides an overview of payer coverage, clinical context, and relevant policy updates. Readers will gain insights into coding benchmarks, laboratory billing practices, and the role of molecular genetic testing in patient care. The summary also highlights associated ICD-10 diagnoses, common modifiers, and related CPT codes, offering a comprehensive view of how CPT 81404 fits into broader laboratory and pathology workflows. This information is valuable for understanding reimbursement trends, compliance requirements, and the evolving landscape of genetic testing in clinical practice.
CPT Code Overview
CPT 81404 is used for molecular pathology procedures, specifically for duplication and deletion analysis of MEN1 (multiple endocrine neoplasia 1) and targeted sequence analysis of 2–5 exons of TP53 (tumor protein 53). This code is commonly billed for genetic testing services that help identify mutations associated with certain endocrine and oncologic conditions. The typical site of service for CPT 81404 is a clinical laboratory, with billing most often occurring under laboratory settings such as place of service codes 19 or 81. These tests play a critical role in guiding diagnosis and management for patients with suspected genetic abnormalities related to MEN1 and TP53.
Clinical & Coding Specifications
Clinical Context
A patient with a suspected or confirmed diagnosis of acute leukemia or myelodysplastic syndrome presents to a hematologist or oncologist. The provider orders molecular genetic testing to evaluate for mutations in the MEN1 gene (associated with multiple endocrine neoplasia type 1) and targeted sequence analysis of 2-5 exons of the TP53 gene (tumor protein 53), which are relevant for prognosis and treatment planning. The specimen is sent to a clinical laboratory (typically place of service 19 or 81) specializing in molecular pathology. The laboratory performs the duplication and deletion analysis for MEN1 and targeted sequencing for TP53, and reports the results back to the ordering provider for clinical interpretation and management.
Coding Specifications
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Modifiers:
- Modifier
26: Used to indicate the professional component of the laboratory service, typically when the physician interprets the results but does not perform the technical portion. - Modifier
91: Used when the same clinical diagnostic laboratory test is repeated on the same patient on the same day to obtain additional information.
- Modifier
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Provider Taxonomies:
Taxonomy Code Specialty Name 291U00000XMolecular Genetic Pathology 207ZP0007XPathology 207Q00000XFamily Medicine Physician -
Site of Service:
- Clinical laboratory settings, typically place of service
19or81.
- Clinical laboratory settings, typically place of service
Related Diagnoses
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C92.00: Acute myelogenous leukemia, not having achieved remission- Relevant for patients undergoing genetic testing to guide treatment and prognosis.
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C92.02: Acute myelogenous leukemia, in remission- Used for monitoring patients post-treatment, where molecular testing may inform relapse risk.
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C92.30: Acute promyelocytic leukemia, not having achieved remission- Indicates a subtype of acute leukemia where genetic analysis may impact therapy.
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C92.32: Acute promyelocytic leukemia, in remission- Used for follow-up and risk assessment.
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C92.40: Acute myelomonocytic leukemia, not having achieved remission- Genetic testing assists in diagnosis and management.
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C92.42: Acute myelomonocytic leukemia, in remission- Used for ongoing monitoring.
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C92.50: Acute monocytic leukemia, not having achieved remission- Genetic analysis helps in classification and treatment decisions.
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C92.52: Acute monocytic leukemia, in remission- Used for surveillance.
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C92.60: Acute erythroid leukemia, not having achieved remission- Genetic testing is important for diagnosis and prognosis.
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C92.62: Acute erythroid leukemia, in remission- Used for post-treatment monitoring.
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C92.A0: Acute panmyelosis with myelofibrosis, not having achieved remission- Genetic analysis may guide therapy.
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C92.A2: Acute panmyelosis with myelofibrosis, in remission- Used for follow-up.
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C92.Z0: Acute leukemia of unspecified cell type, not having achieved remission- Genetic testing helps clarify diagnosis.
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C92.Z2: Acute leukemia of unspecified cell type, in remission- Used for monitoring.
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C94.00: Acute erythroid leukemia, not having achieved remission- Relevant for diagnostic and prognostic purposes.
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C94.02: Acute erythroid leukemia, in remission- Used for surveillance.
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C94.6: Aleukemic, subleukemic and pancytopenia leukemias, not having achieved remission / in remission- Genetic testing may assist in diagnosis and management.
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D46.0: Refractory anemia without ring sideroblasts- Indicates myelodysplastic syndrome subtype where molecular testing is useful.
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D46.1: Refractory anemia with ring sideroblasts- Genetic analysis may inform prognosis.
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D46.20: Refractory anemia with excess of blasts, unspecified- Used for diagnosis and risk stratification.
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D46.21: Refractory anemia with excess of blasts, type 1- Genetic testing assists in classification.
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D46.22: Refractory anemia with excess of blasts, type 2- Used for further risk assessment.
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D46.A: Refractory anemia, unspecified- Genetic analysis helps clarify diagnosis.
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D46.B: Refractory cytopenia with multilineage dysplasia- Molecular testing may guide management.
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D46.C: Refractory anemia with excess blasts in transformation- Indicates progression to acute leukemia; genetic testing is critical.
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D46.4: Refractory anemia with ring sideroblasts and thrombocytosis- Genetic analysis may inform treatment.
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D46.Z: Myelodysplastic syndrome, unspecified- Used for diagnosis and prognosis.
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D46.9: MDS, unspecified- Genetic testing assists in classification and management.
Related CPT Codes
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81405: Tier 2 Molecular Pathology Procedure; full gene sequence or targeted sequence analysis of >5 exons of TP53 and duplication/deletion analysis for MEN1.- Used when a more comprehensive analysis of TP53 (more than 5 exons) is required, often as an alternative or in addition to
81404.
- Used when a more comprehensive analysis of TP53 (more than 5 exons) is required, often as an alternative or in addition to
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81406: RET (ret-proto-oncogene) full gene sequence (non-covered).- Used for sequencing the RET gene, which is not directly related to MEN1 or TP53 testing, and is not covered by most payors. Not commonly used together with
81404.
- Used for sequencing the RET gene, which is not directly related to MEN1 or TP53 testing, and is not covered by most payors. Not commonly used together with
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81479: Unlisted molecular pathology procedure (use when analyte not represented by existing Tier 1 or Tier 2 codes).- Used when a molecular pathology test is performed for an analyte not covered by existing codes. May be used as an alternative if the specific test is not represented by
81404or81405.
- Used when a molecular pathology test is performed for an analyte not covered by existing codes. May be used as an alternative if the specific test is not represented by
National Reimbursement Benchmarks
National mean rates for CPT code 81404 among commercial payers are highest with Blue Cross Blue Shield at $249.98 and lowest with Aetna at $197.99. The BUCA (average commercial) mean rate is $218.78, which is above Aetna and UnitedHealth Group but below Blue Cross Blue Shield and Cigna. Medicare rates are not available in the input for comparison.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Cigna exhibits the widest spread at $233.00, indicating substantial variability in reimbursement, while Blue Cross Blue Shield has the tightest range at $93.40, suggesting more consistent rates. Aetna, UnitedHealth Group, and BUCA fall in between, with ranges of $114.40, $129.67, and $128.50, respectively.
The table and chart below present the full breakdown of national benchmarks for CPT code 81404 across major commercial payers.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.