Summary & Overview
CPT 81406: Tier 2 Molecular Pathology Laboratory Procedure
CPT code 81406 is a Tier 2 Molecular Pathology Procedure used for specialized genetic and molecular testing in clinical laboratories. This code covers tests for specific analytes that are not individually listed in Tier 1, making it a critical tool for advanced diagnostics in areas such as genetic screening, chromosomal analysis, and metabolic disorder evaluation. Nationally, molecular pathology is a rapidly evolving field, and CPT code 81406 plays a significant role in expanding access to precision medicine.
Major payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare provide coverage for these procedures, reflecting broad acceptance and integration into standard laboratory practice. Readers will gain insight into payer coverage, clinical indications, and related coding benchmarks, as well as policy updates relevant to laboratory medicine. The publication also highlights associated ICD-10 diagnoses, common modifiers, and related CPT codes, offering a comprehensive overview for stakeholders in clinical pathology and laboratory medicine.
This summary provides a clear understanding of the clinical context, payer landscape, and coding framework for CPT code 81406, supporting informed decision-making for laboratories, clinicians, and healthcare administrators.
CPT Code Overview
CPT code 81406 represents a Tier 2 Molecular Pathology Procedure, encompassing specialized laboratory tests for specific analytes not individually listed in Tier 1. These procedures are typically performed in an independent laboratory setting, designated as Place of Service 81. The service type is molecular pathology, which involves advanced genetic and molecular testing to aid in diagnosis, risk assessment, and treatment planning. These tests are essential for identifying genetic mutations, chromosomal anomalies, and other molecular markers relevant to patient care.
Clinical & Coding Specifications
Clinical Context
A patient is referred to an independent laboratory for molecular pathology testing to evaluate for potential genetic or chromosomal anomalies. The ordering provider may be a family medicine physician or a specialist in pathology. The laboratory performs a Tier 2 molecular pathology procedure, which involves testing for specific analytes not individually listed in Tier 1. The results may inform diagnosis, screening, or genetic counseling, and are typically used in cases where there is a family history of genetic disease, suspicion of metabolic disorders, or the need for chromosomal abnormality screening. The workflow includes specimen collection, laboratory analysis, and interpretation by a qualified pathologist.
Coding Specifications
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Modifiers:
- Modifier
26: Used to indicate the professional component of the service, such as interpretation of laboratory results by a physician or pathologist. - Modifier
TC: Used to indicate the technical component, which covers the laboratory's performance of the test, including equipment and staff.
- Modifier
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Provider Taxonomies:
Code Specialty 207ZP0102XPathology - Clinical Pathology/Laboratory Medicine 207L00000XAnatomic Pathology 207Q00000XFamily Medicine Physician
These taxonomies represent providers who may order, perform, or interpret molecular pathology procedures.
Related Diagnoses
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Z13.79: Encounter for other screening for genetic and chromosomal anomalies. Used when the test is performed for screening purposes in asymptomatic patients. -
Q99.9: Chromosomal abnormality, unspecified. Relevant when the test is ordered due to suspicion or confirmation of a chromosomal disorder. -
E88.9: Metabolic disorder, unspecified. Applied when the molecular pathology procedure is used to investigate possible metabolic conditions. -
Z84.81: Family history of carrier of genetic disease. Indicates testing due to a known family history, supporting genetic risk assessment. -
Z31.430: Encounter for genetic counseling. Used when the procedure is part of a genetic counseling session, either pre- or post-test.
Related CPT Codes
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81407: Molecular pathology procedure, Level 8. This code represents a higher complexity molecular pathology test and may be used as an alternative or in conjunction with81406depending on the analyte tested. -
81220: CFTR gene analysis. Used for cystic fibrosis testing; may be ordered alongside81406if multiple genetic tests are required. -
81225: CYP2C19 gene analysis. Used for pharmacogenetic testing; can be performed in the same workflow as81406for broader genetic assessment. -
81230: CYP2D6 gene analysis. Also used for pharmacogenetic testing and may be ordered with81406for comprehensive molecular profiling.
These codes are related by their use in molecular pathology and genetic testing workflows. Some may be used together for multi-gene panels, while others serve as alternatives based on clinical need.
National Reimbursement Benchmarks
National mean rates for CPT 81406 show that BUCA (the average commercial benchmark) is $226.36, while Medicare rates are not available in the input. Among individual commercial payers, Blue Cross Blue Shield has the highest mean rate at $265.66, followed by Cigna at $255.44, UnitedHealth Group at $223.25, and Aetna at $179.88.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Cigna exhibits the widest spread ($340.00 - $87.00 = $253.00), indicating substantial variability in reimbursement. Blue Cross Blue Shield has the tightest range ($283.00 - $194.86 = $88.14), suggesting more consistent rates. The table and chart below present the full breakdown of national benchmarks for each payer.
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