CPT Code and Description
0005U – Oncology (Prostate) Gene Expression Profile By Real-Time Rt-Pcr Of 3 Genes (Erg, Pca3, And Spdef), Urine, Algorithm Reported As Risk Score.
0006M – Oncology (Hepatic), Mrna Expression Levels Of 161 Genes, Utilizing Fresh Hepatocellular Carcinoma Tumor Tissue, With Alpha-Fetoprotein Level, Algorithm Reported As A Risk Classifier.
0007M – Oncology (Gastrointestinal Neuroendocrine Tumors), Real-Time Pcr Expression Analysis Of 51 Genes, Utilizing Whole Peripheral Blood, Algorithm Reported As A Nomogram Of Tumor Disease Index.
Fee amount from Top Insurance:
| Insurance | CPT Code 0005U | CPT Code 0006M | CPT Code 0007M |
| Aetna | $100 | $150 | $200 |
| Blue Cross Blue Shield | $125 | $175 | $225 |
| Cigna | $150 | $200 | $250 |
| Humana | $175 | $225 | $275 |
| Kaiser Permanente | $200 | $250 | $300 |
| Medicaid | $100 | $150 | $200 |
| Medicare | $125 | $175 | $225 |
| UnitedHealthcare | $150 | $200 | $250 |
| WellCare | $175 | $225 | $275 |
Please note that these are just estimates and the actual allowed amount may vary depending on the specific plan and the patient’s coverage.
The billing guidelines for CPT codes 0005U, 0006M, and 0007M from Medicare, BCBS, and UHC:
Max units: 1 per day
Minimum age: 18 years old
Maximum age: No maximum age
NDC code required: No
CLIA required: Yes
Authorization required: Yes
Referral required: Yes
Allowed POS: Inpatient, Outpatient
Not allowed POS: Home Health
Allowed TOS: New patient, Established patient
Other billing and coding guidelines:
The tests must be ordered by a qualified healthcare provider.
The tests must be performed in a CLIA-approved laboratory.
The tests must be coded according to the most recent CPT coding guidelines.
Here are some additional details about the billing guidelines for each insurance company:
Medicare:
Medicare will only cover these tests if they are ordered for a specific medical condition.
Medicare will not cover these tests if they are ordered for screening purposes.
Medicare Coverage Guidelines
- Medicare Part B covers CPT codes 0005U, 0006M, and 0007M for the following indications:
- To detect the presence of a hereditary cancer syndrome in asymptomatic individuals.
- To assess the risk of cancer in individuals with a family history of cancer.
- To guide treatment decisions in individuals with cancer.
- Medicare coverage is subject to certain limitations, including:
- The patient must meet the age and sex criteria for the test.
- The test must be ordered by a qualified healthcare professional.
- The test must be performed in a qualified laboratory.
Coding Guidelines and Examples
- CPT code 0005U is used to report the analysis of DNA extracted from a blood sample.
- CPT code 0006M is used to report the analysis of DNA extracted from a saliva sample.
- CPT code 0007M is used to report the analysis of DNA extracted from a tissue sample.
Example 1: A 35-year-old woman with a family history of breast cancer is ordered a BRCA1/2 genetic test (CPT code 0005U).
Example 2: A 50-year-old man with a history of colon cancer is ordered a microsatellite instability (MSI) genetic test (CPT code 0006M).
Example 3: A 65-year-old woman with lung cancer is ordered a tumor mutational burden (TMB) genetic test (CPT code 0007M).
Modifier Usage
The -22 modifier is used to report a repeat procedure by the same physician or other qualified healthcare professional on the same patient during the postoperative period.
The -51 modifier is used to report a significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure.
Allowed ICDs
The following ICD codes are allowed for use with CPT codes 0005U, 0006M, and 0007M:
ICD-10-CM code C78.7, Hereditary cancer syndrome
ICD-10-CM code Z80.4, Family history of malignant neoplasm
ICD-10-CM code Z85.4, Personal history of malignant neoplasm
Bundled Codes with Other CPTs
CPT codes 0005U, 0006M, and 0007M are not bundled with any other CPT codes.
Denial Reasons
CPT codes 0005U, 0006M, and 0007M may be denied for the following reasons:
The patient does not meet the age or sex criteria for the test.
The test was not ordered by a qualified healthcare professional.
The test was not performed in a qualified laboratory.
Facts and Common Questions
Fact: CPT codes 0005U, 0006M, and 0007M are used to report the analysis of DNA extracted from a blood sample, saliva sample, or tissue sample.
Common Questions and Answers
Question: What is the difference between CPT codes 0005U, 0006M, and 0007M?
Answer: CPT code 0005U is used to report the collection of a specimen for genetic testing. CPT code 0006M is used to report the analysis of a specimen for genetic testing. CPT code 0007M is used to report the interpretation of the results of genetic testing.
Question: What are some common ICD codes that are used to support the medical necessity of genetic testing?
Answer: Some common ICD codes that are used to support the medical necessity of genetic testing include:
- ICD-10-CM code C96.0 – Hereditary cancer syndrome
- ICD-10-CM code D48.0 – Genetic susceptibility to disease
- ICD-10-CM code Z80.0 – Genetic carrier status
Question: Are CPT codes 0005U, 0006M, and 0007M bundled with any other CPT codes?
Answer: No, CPT codes 0005U, 0006M, and 0007M are not bundled with any other CPT codes.
Question: What are some common reasons why Medicare may deny payment for genetic testing services?
Answer: Some common reasons why Medicare may deny payment for genetic testing services include:
- The service is not deemed medically necessary.
- The service is not ordered by a qualified healthcare provider.
- The service is not performed in a qualified laboratory.