Summary & Overview
CPT 81431: Genomic Sequencing for Hearing Loss Duplication/Deletion Analysis
CPT code 81431 represents a genomic sequencing procedure focused on the analysis of duplications and deletions associated with hearing loss. This advanced molecular assay is increasingly important in the diagnosis and management of hereditary hearing conditions, offering clinicians precise genetic information to inform patient care. The code is typically billed from laboratory settings, reflecting the specialized nature of the testing.
Major national payers, including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, are covered in this analysis. Readers will gain insight into payer coverage trends, relevant policy updates, and clinical benchmarks for the use of 81431. The publication also provides context on related codes, such as those for CFTR gene analysis and unlisted molecular pathology procedures, and outlines common modifiers used in billing. Additionally, the summary includes associated taxonomies and ICD-10 diagnoses relevant to hearing loss and genetic screening.
This article offers a comprehensive overview of 81431, equipping stakeholders with the latest information on payer coverage, clinical applications, and billing practices for genomic sequencing procedures targeting hearing loss.
CPT Code Overview
CPT code 81431 is used to report genomic sequencing procedures specifically for hearing loss duplication and deletion analysis. This code falls under Genomic Sequencing Procedures and Other Molecular Multianalyte Assays, reflecting advanced molecular diagnostic testing. The typical site of service for this procedure is a laboratory (POS 81), where specialized genetic testing is performed to identify genetic causes of hearing loss. This testing supports clinical decision-making by providing detailed genetic information relevant to patient care.
Clinical & Coding Specifications
Clinical Context
A patient, often a child or young adult, presents with symptoms of hearing loss. The clinician suspects a genetic etiology, particularly involving gene duplications or deletions associated with hearing impairment. The patient may also have a family history of cystic fibrosis or other genetic disorders. The provider orders genomic sequencing procedures, specifically the hearing loss duplication/deletion analysis (CPT 81431), to identify potential genetic causes. The specimen is sent to a laboratory (POS 81) specializing in molecular genetics. Results are interpreted by a medical geneticist or a Ph.D. in medical genetics, and findings may inform further management or genetic counseling.
Coding Specifications
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Modifiers:
26: Professional Component – Used when only the interpretation of the test is performed, not the technical aspect.TC: Technical Component – Used when only the technical performance of the test (e.g., running the assay in the lab) is billed.
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Provider Taxonomies:
| Taxonomy Code | Specialty Name |
|---|---|
207SG0201X | Medical Genetics, Ph.D. Medical Genetics |
207SG0202X | Medical Genetics, Clinical Genetics (M.D.) |
207SG0203X | Medical Genetics, Clinical Biochemical Genetics |
207SG0205X | Medical Genetics, Clinical Molecular Genetics |
These specialties represent providers qualified to order, interpret, and report genomic sequencing procedures for hearing loss and related genetic conditions.
Related Diagnoses
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E84.0: Cystic fibrosis with pulmonary manifestations- Relevant when hearing loss is associated with cystic fibrosis affecting the lungs.
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E84.1: Cystic fibrosis with intestinal manifestations- Used if hearing loss occurs in patients with cystic fibrosis presenting with gastrointestinal symptoms.
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E84.8: Cystic fibrosis with other manifestations- Applies when hearing loss is part of other, less common presentations of cystic fibrosis.
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E84.9: Cystic fibrosis, unspecified- Used when cystic fibrosis is diagnosed but the specific manifestation is not detailed; may be relevant for broad genetic screening.
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Z13.79: Encounter for other screening for genetic and chromosomal anomalies- Used for patients undergoing genetic screening for hearing loss or related chromosomal anomalies, even if no symptoms are present.
Related CPT Codes
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81220: CFTR gene analysis; full gene sequence- Used to analyze the entire CFTR gene, often in cases where cystic fibrosis is suspected. May be ordered alongside
81431if hearing loss is part of a broader genetic syndrome.
- Used to analyze the entire CFTR gene, often in cases where cystic fibrosis is suspected. May be ordered alongside
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81221: CFTR gene analysis; known familial variants- Used when a specific familial CFTR variant is known. Can complement
81431in families with known genetic mutations.
- Used when a specific familial CFTR variant is known. Can complement
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81222: CFTR gene analysis; duplication/deletion variants- Specifically targets CFTR gene duplications/deletions. May be used as an alternative or adjunct to
81431if cystic fibrosis is suspected.
- Specifically targets CFTR gene duplications/deletions. May be used as an alternative or adjunct to
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81479: Unlisted molecular pathology procedure- Used for molecular pathology procedures not otherwise specified. May be used when a test does not fit established CPT codes, including rare or novel analyses related to hearing loss.
These codes are commonly used together or as alternatives depending on the clinical scenario and the genetic findings being investigated.
National Reimbursement Benchmarks
National mean rates for CPT code 81431 show that Blue Cross Blue Shield has the highest average reimbursement at $593.18, while Aetna is the lowest among the major commercial payers at $496.50. The BUCA (average commercial) mean rate stands at $537.27, which is higher than Aetna and UnitedHealth Group, but lower than 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 $586.33, indicating substantial variability in reimbursement. Blue Cross Blue Shield also shows a broad range of $275.42. In contrast, Aetna has the tightest range at $217.00, suggesting more consistent rates across providers. UnitedHealth Group and BUCA fall in between, with ranges of $330.00 and $305.50, respectively.
The table and chart below present a detailed breakdown of national mean rates and percentile values for each payer.
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