Summary & Overview
CPT 81435: Genetic Panel for Hereditary Colon Cancer Disorders
CPT code 81435 represents a genomic sequence analysis panel for hereditary colon cancer disorders, including conditions like Lynch syndrome and PTEN hamartoma syndrome. This code is significant nationally as it covers the sequencing of at least 10 genes, providing a comprehensive approach to genetic testing for patients with a family or personal history of colon cancer. The procedure is typically performed in laboratory settings and is essential for identifying genetic susceptibility, which can inform clinical management and preventive strategies.
Major payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare provide coverage for this service, reflecting its importance in both clinical and policy contexts. Readers will gain insights into payer coverage benchmarks, recent policy updates, and the clinical relevance of this genetic testing panel. The publication also explores associated diagnoses, related CPT codes, and common billing modifiers, offering a thorough overview for stakeholders in medical genetics, pathology, and family medicine.
This summary provides a clear understanding of the role of CPT code 81435 in hereditary colon cancer screening, its coverage landscape, and its impact on patient care and healthcare policy.
CPT Code Overview
CPT code 81435 is used for genomic sequence analysis panels targeting hereditary colon cancer disorders, such as Lynch syndrome and PTEN hamartoma syndrome. This code requires sequencing of at least 10 genes and is classified under genetic testing. The typical site of service for this procedure is a laboratory setting (Place of Service 81). This comprehensive genetic panel plays a critical role in identifying individuals at risk for hereditary colon cancer, enabling informed clinical decision-making and personalized patient care.
Clinical & Coding Specifications
Clinical Context
A patient with a family history of colon cancer or a personal history of colon neoplasms is referred for genetic testing to assess hereditary risk. The ordering provider, often a medical geneticist, clinical geneticist, or family medicine physician, requests a comprehensive genomic sequence analysis panel for hereditary colon cancer disorders, such as Lynch syndrome or PTEN hamartoma syndrome. The laboratory (Place of Service 81) performs sequencing of at least 10 relevant genes. Results inform clinical management, surveillance, and counseling for the patient and potentially their relatives.
Coding Specifications
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Modifier
26: Used when only the professional component (interpretation of results) is billed, typically by the physician or geneticist. -
Modifier
59: Indicates a distinct procedural service, used when multiple procedures are performed and need to be reported separately.
| Provider Taxonomy Code | Specialty Description |
|---|---|
207SG0201X | Medical Genetics, Clinical Genetics (M.D.) |
207ZP0213X | Pathology, Molecular Genetic Pathology |
207Q00000X | Family Medicine Physician |
Related Diagnoses
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Z80.0Family history of malignant neoplasm of digestive organs- Indicates a hereditary risk, supporting the need for genetic testing.
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C18.9Malignant neoplasm of colon, unspecified- Represents a current diagnosis of colon cancer, relevant for identifying hereditary syndromes.
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Z85.038Personal history of other malignant neoplasm of large intestine- Reflects a prior diagnosis, justifying genetic evaluation for recurrence risk.
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D12.6Benign neoplasm of colon, unspecified- May prompt genetic testing if there is suspicion of hereditary syndromes.
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Z15.09Genetic susceptibility to other malignant neoplasm- Used when genetic risk is identified, supporting the use of a genomic sequence panel.
Related CPT Codes
| CPT Code | Description | Clinical Relationship |
|---|---|---|
81292 | MLH1 gene analysis | Component gene analysis for Lynch syndrome; may be used individually or as part of panel 81435. |
81295 | MSH2 gene analysis | Component gene analysis for Lynch syndrome; may be used individually or as part of panel 81435. |
81298 | MSH6 gene analysis | Component gene analysis for Lynch syndrome; may be used individually or as part of panel 81435. |
81301 | PTEN gene analysis | Component gene analysis for PTEN hamartoma syndrome; may be used individually or as part of panel 81435. |
81436 | Hereditary colon cancer disorders, duplication/deletion analysis panel | Complementary panel to 81435, focusing on duplication/deletion analysis rather than sequencing; may be used together for comprehensive assessment or as an alternative depending on clinical need. |
National Reimbursement Benchmarks
National mean rates for CPT code 81435 show that Blue Cross Blue Shield has the highest average reimbursement at $755.88, while Aetna and UnitedHealth Group are lower at $486.03 and $520.58, respectively. The BUCA (average commercial) mean rate stands at $583.39, notably higher than 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. Blue Cross Blue Shield exhibits the widest spread at $608.00, indicating substantial variability in rates. Cigna also shows a large range of $538.00. In contrast, Aetna has a tighter range of $213.29, suggesting more consistent reimbursement levels. UnitedHealth Group and BUCA have moderate dispersions of $321.00 and $376.50, respectively.
The table and chart below present a detailed breakdown of national benchmarks for each payer, including mean rates and percentile values.
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