Summary & Overview
CPT 81417: Exome Sequence Reanalysis for Updated Genetic Interpretation
CPT code 81417 is a specialized procedure for the reanalysis of a patient's exome gene sequence, leveraging new scientific information that was unavailable during the initial evaluation. This code is increasingly important as advances in genomics continually reshape the understanding of genetic variants and their clinical significance. The service is typically performed in independent laboratories and is part of the broader category of genomic sequencing and molecular multianalyte assays.
Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, provide coverage for this procedure, reflecting its growing relevance in precision medicine and oncology. The publication offers a comprehensive overview of payer coverage, clinical context, and policy updates related to 81417. Readers will gain insights into benchmarks for utilization, recent changes in payer policies, and the clinical scenarios where exome reanalysis is most impactful, such as in the management of various malignant neoplasms.
This summary equips healthcare professionals, laboratory administrators, and policy stakeholders with the latest information on the role of exome reanalysis in patient care, payer landscape, and evolving clinical guidelines. The content is designed to inform decision-making and support understanding of how genomic reanalysis is integrated into modern laboratory medicine.
CPT Code Overview
CPT code 81417 represents the reanalysis of an existing patient exome gene sequence, specifically in light of new information that was not available at the time of the initial evaluation. This procedure is classified under Genomic Sequencing Procedures and Other Molecular Multianalyte Assays. The typical site of service for this code is an Independent Laboratory (Place of Service 81). This service is critical for updating genetic interpretations as new scientific discoveries emerge, ensuring that patients benefit from the most current genomic insights.
Clinical & Coding Specifications
Clinical Context
A patient with a history of a malignant neoplasm, such as lung, breast, colon, prostate, or pancreatic cancer, previously underwent exome sequencing to identify potential genetic mutations relevant to their diagnosis and treatment. As new genetic information or research becomes available, the laboratory receives a request to reanalyze the patient's existing exome sequence. This reanalysis aims to uncover additional genetic variants or mutations that were not identifiable during the initial evaluation, potentially impacting clinical management or therapeutic decisions. The procedure is typically performed in an independent laboratory setting, with results interpreted by specialists in molecular genetic pathology or clinical pathology.
Coding Specifications
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Modifiers:
- Modifier
26: Used to indicate the professional component, representing the interpretation and reporting of the exome reanalysis by a qualified physician or specialist. - Modifier
TC: Used to indicate the technical component, representing the performance of the laboratory procedure, including specimen processing and analysis.
- Modifier
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Provider Taxonomies:
207ZP0102X: Pathology - Clinical Pathology/Laboratory Medicine207ZP0007X: Pathology - Molecular Genetic Pathology207L00000X: Anatomic Pathology & Clinical Pathology
These taxonomies represent providers specializing in laboratory medicine, molecular genetic pathology, and anatomic/clinical pathology, all of whom may be involved in the exome reanalysis process.
Related Diagnoses
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C34.90: Malignant neoplasm of unspecified part of unspecified bronchus or lung- Relevant for patients with lung cancer undergoing exome reanalysis to identify genetic mutations impacting prognosis or therapy.
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C50.919: Malignant neoplasm of unspecified site of unspecified female breast- Used for breast cancer patients where exome reanalysis may reveal new actionable genetic variants.
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C18.9: Malignant neoplasm of colon, unspecified- Applies to colon cancer cases, supporting the search for genetic changes that could influence treatment.
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C61: Malignant neoplasm of prostate- Pertinent for prostate cancer patients, where updated exome analysis may inform targeted therapies.
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C25.9: Malignant neoplasm of pancreas, unspecified- Used for pancreatic cancer patients, enabling identification of novel genetic alterations through reanalysis.
Related CPT Codes
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81416: The lab analyst performs an exome gene sequence analysis in a relative of the patient to create a reference exome gene sequence, which the lab analyst can compare to the patient’s exome to evaluate an unexplained disorder or syndrome in the patient.- This code is related when family-based comparisons are needed to interpret the patient's exome findings, often used in conjunction with
81417for comprehensive genetic evaluation.
- This code is related when family-based comparisons are needed to interpret the patient's exome findings, often used in conjunction with
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81415: The lab analyst performs an exome gene sequence analysis to look for genetic changes that could account for an unexplained disorder or syndrome in the patient.- This code is used for the initial exome sequencing of the patient, which precedes the reanalysis described by
81417. It is commonly used as a precursor to81417.
- This code is used for the initial exome sequencing of the patient, which precedes the reanalysis described by
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81418: Test to evaluate a blood or saliva specimen for changes in at least six genes that may impact metabolism of many therapeutic drugs. The test must include CYP2C19 and CYP2D6 variant analysis and CYP2D6 duplication/deletion analysis.- This code is related when pharmacogenomic testing is indicated, which may be performed alongside or after exome sequencing to inform drug therapy decisions. It is an alternative or adjunct to
81417depending on clinical needs.
- This code is related when pharmacogenomic testing is indicated, which may be performed alongside or after exome sequencing to inform drug therapy decisions. It is an alternative or adjunct to
National Reimbursement Benchmarks
National mean rates for CPT code 81417 show that BUCA (average commercial) payers reimburse at $263.54, while individual commercial payers range from $233.50 (Aetna) to $319.78 (Blue Cross Blue Shield). 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 ($357.00 - $89.67 = $267.33), indicating substantial variability in contracted rates. In contrast, Aetna has the tightest range ($272.00 - $169.00 = $103.00), suggesting more consistent reimbursement levels.
The table and chart below present a detailed breakdown of national payer benchmarks for CPT code 81417, including mean rates and percentile values.
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