CPT code and Description:
CPT Code: 88120
Cytopathology, In Situ Hybridization (Eg, Fish), Per Specimen; Each Probe
CPT Code 81161: DMD Gene Analysis (Duchenne Muscular Dystrophy)
DMD (Duchenne Muscular Dystrophy) gene analysis, known mutation, deletion, duplication testing.
CPT Code 81408: Hereditary Peripheral Neuropathies Gene Panel
Genetic testing for hereditary peripheral neuropathies (e.g., Charcot-Marie-Tooth disease).
Approximate Fee Amount:
$538.48 (Non-facility)
$54.41 (Facility)
$484.06 (Other)
Insurance Guidelines:
Insurance coverage for CPT 88120 typically includes:
Verification of medical necessity based on patient diagnosis.
CPT Code Guidelines and Usage:
Prior authorization may be required for coverage.
Coverage often includes genetic testing and cancer diagnostics.
Medicare and Medicaid may have specific policies and limitations for coverage.
Used for cytopathology in situ hybridization techniques, specifically fluorescence in situ hybridization (FISH).
Applicable for detecting specific nucleic acid sequences in cytological specimens.
Ensures accurate genetic or chromosomal analysis for diagnostic purposes.
Often used in cancer diagnostics, prenatal testing, and genetic disorder screenings.
Utilized for diagnosing or confirming Duchenne Muscular Dystrophy (DMD) or Becker Muscular Dystrophy (BMD).
Can be used for carrier testing in females with a family history of DMD/BMD.
Essential for prenatal testing if the mutation is known in the family.
Molecular Pathology
- Physician (M.D. or D.O.) interpretation of a molecular pathology procedure (e.g., CPT codes 81161-81408) may be reported with HCPCS code G0452 when medically reasonable and
necessary. It shall not be reported with CPT code 88291 (Cytogenetics and molecular cytogenetics, interpretation and report). - Molecular pathology procedures (e.g., CPT codes 81161-81408) include all aspects of sample preparation, cell lysis, internal measures to assure adequate quantity of DNA or RNA, and
performance of the assay. These procedures include DNA analysis and/or RNA analysis. - Quantitation of extracted DNA and/or RNA is included in the payment for a molecular pathology procedure (e.g., CPT codes 81161-81408). Other HCPCS/CPT codes such as CPT code 84311
(Spectrophotometry…not elsewhere specified) shall not be reported for this quantitation. - Scraping tumor off an unstained slide, if performed, is included in the payment for a molecular pathology procedure (e.g., CPT codes 81161-81408). A provider/supplier shall not report
microdissection (CPT codes 88380 or 88381) for this process. - A Tier 1 or Tier 2 molecular pathology procedure CPT code should not, in general, be reported with a genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with
algorithmic analysis, or proprietary laboratory analysis CPT code where the CPT code descriptor includes testing for the analyte described by the Tier 1 or Tier 2 molecular pathology code.
Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the beneficiary and
using the results in the management of the beneficiary’s specific medical problem. - If one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing
procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure
performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the
component test results when medically reasonable and necessary. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and
ordered by the physician who is treating the beneficiary and using the results in the management of the beneficiary’s specific medical problem.
Question and answer on CPT 88120
Q: What conditions justify the use of CPT 88120?
A: CPT 88120 is justified for conditions requiring genetic or chromosomal analysis, such as cancer diagnostics and genetic disorders.
Q: Is prior authorization always required for CPT 88120?
A: Prior authorization requirements vary by insurance provider. It is often required to ensure coverage.
Q: How should the procedure be documented for insurance claims?
A: Documentation should include detailed patient history, indication for the test, test results, and medical necessity.
Q: What are common reasons for denial of CPT 88120 claims?
A: Common reasons include lack of medical necessity, missing prior authorization, incorrect coding, duplicate claims, and inadequate documentation.
Q: Can CPT 88120 be used for prenatal genetic testing?
A: Yes, it is often used for prenatal genetic testing to detect chromosomal abnormalities
Reimbursement Guidelines
According to the American Medical Association (AMA) molecular pathology procedure code selection is typically based on the specific gene(s) that is being analyzed. Genes are described using Human Genome Organization (HUGO) approved gene names and are italicized in the code descriptors. Gene names were taken from tables of the HUGO Gene Nomenclature Committee
(HGNC) at the time the CPT codes were developed. The AMA has provided Claim Designations using these abbreviated gene names and/or analytes. These Claim Designations are cross walked to the appropriate codes to report on the Molecular Pathology Gene Table provided in the Pathology and Laboratory section of the AMA CPT codebook.
Codes that describe tests to assess for the presence of gene variants use common gene variant names. Typically, all of the listed variants would be tested. However, these lists are not exclusive. If other variants are also tested in the analysis, they would be included in the procedure and not reported separately. The molecular pathology codes include all analytical services performed in the test (eg, cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection). Tier 1 molecular pathology codes represent gene-specific and genomic procedures. Molecular pathology procedures that are not specified in a Tier 1 code should be reported using either the appropriate Tier 2 code or the unlisted molecular pathology procedure code, 81479.
Tier 2 molecular pathology codes are used to report procedures not listed in Tier 1 molecular pathology codes. They are arranged by level of technical resources and interpretive work by the physician or other qualified health care professional. Each Tier 2 code lists the specific analytes associated with the procedure code level. The Tier 2 code reported must have the specific analyte listed under the code or is a code match to the Claim Designation on the AMA Molecular Pathology Gene Table. In order to identify the analyte being tested under the code submitted, an appropriate Claim Designation code or Abbreviated Gene Name must be submitted on the claim. This information should be submitted in field 2400 SV101-7 in the electronic claim form or in the shaded area of the service line in section 24 on a paper claim form. In order to identify the information, a ZZ qualifier is required to be placed without a space or hyphen in front of the Claim Designation code or Abbreviated Gene Name (example: ZZCLRN1).
Tier 2 Molecular Pathology Codes
81400 81401 81402 81403 81404 81405 81406 81407 81408
