Summary & Overview
CPT 81438: Genomic Sequencing for Hereditary Neuroendocrine Tumor Disorders
CPT code 81438 represents genomic sequencing for hereditary neuroendocrine tumor disorders, specifically targeting duplication and deletion analysis. This procedure is essential for identifying genetic mutations that may predispose individuals to neuroendocrine tumors, enabling more precise diagnosis and informing treatment strategies. The code is most commonly utilized in independent laboratory settings, reflecting the specialized nature of genetic testing.
Key payers covered in this analysis include Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare, all of which play significant roles in national reimbursement and coverage policies for genetic testing services. Readers will gain insights into clinical benchmarks, policy updates, and the broader context of hereditary cancer panel testing. The publication also addresses relevant modifiers, associated taxonomies, and ICD-10 diagnoses linked to neuroendocrine tumor disorders, providing a comprehensive overview of coding and billing considerations.
This summary offers a clear understanding of the clinical and administrative aspects of CPT code 81438, equipping stakeholders with the information needed to navigate evolving payer policies and regulatory requirements in the field of medical genetics.
CPT Code Overview
CPT code 81438 is used to report genomic sequencing procedures for hereditary neuroendocrine tumor disorders, specifically focusing on duplication and deletion analysis. This code is part of the broader category of hereditary cancer panels, which play a critical role in identifying genetic mutations associated with neuroendocrine tumors. The typical site of service for this procedure is an independent laboratory (POS 81), where specialized genetic testing is performed to support clinical decision-making and patient management.
Clinical & Coding Specifications
Clinical Context
A patient presents with a personal or family history suggestive of hereditary neuroendocrine tumor disorders, such as malignant carcinoid tumors affecting the gastrointestinal tract. The ordering provider, typically a specialist in medical genetics, requests genomic sequencing to assess for duplication or deletion mutations associated with these disorders. The procedure corresponding to CPT code 81438 is performed in an independent laboratory (Place of Service 81). The workflow involves specimen collection, laboratory analysis for relevant genetic alterations, and interpretation by a qualified genetics professional. Results inform diagnosis, prognosis, and potential management strategies for hereditary neuroendocrine tumor syndromes.
Coding Specifications
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Modifier
26: Used to indicate the professional component of the service, such as interpretation of the genetic test results by a qualified provider. -
Modifier
59: Used to denote a distinct procedural service, typically when multiple procedures are performed and need to be reported separately.
| Modifier Code | Description |
|---|---|
26 | Professional Component |
59 | Distinct Procedural Service |
Associated Provider Taxonomies:
207SG0201X- Medical Genetics, Ph.D. Medical Genetics207SC0300X- Medical Genetics, Clinical Genetics (M.D.)207SG0202X- Medical Genetics, Clinical Biochemical Genetics207SG0203X- Medical Genetics, Clinical Cytogenetics207SG0205X- Medical Genetics, Clinical Molecular Genetics
These taxonomies represent providers specializing in medical genetics, including Ph.D. and M.D. clinical genetics, biochemical genetics, cytogenetics, and molecular genetics.
Related Diagnoses
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C7A.010- Malignant carcinoid tumor of the duodenum- Relevant for patients with neuroendocrine tumors in the duodenum, indicating possible hereditary etiology.
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C7A.011- Malignant carcinoid tumor of the jejunum- Indicates neuroendocrine tumors in the jejunum, supporting the need for genetic analysis.
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C7A.012- Malignant carcinoid tumor of the ileum- Used when the ileum is affected by a carcinoid tumor, which may be hereditary.
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C7A.019- Malignant carcinoid tumor of the small intestine, unspecified portion- Applies to cases where the specific site in the small intestine is not identified, but a carcinoid tumor is present.
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C7A.020- Malignant carcinoid tumor of the appendix- For patients with neuroendocrine tumors in the appendix, potentially linked to hereditary syndromes.
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C7A.021- Malignant carcinoid tumor of the cecum- Indicates carcinoid tumors in the cecum, relevant for genetic testing.
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C7A.022- Malignant carcinoid tumor of the ascending colon- Used for neuroendocrine tumors in the ascending colon, supporting hereditary analysis.
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C7A.023- Malignant carcinoid tumor of the transverse colon- Applies to cases with carcinoid tumors in the transverse colon, where genetic testing may be indicated.
Each diagnosis code represents a clinical scenario where hereditary neuroendocrine tumor disorder testing (CPT code 81438) may be clinically relevant.
Related CPT Codes
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81211- BRCA1, BRCA2 gene analysis, full sequence analysis- Used for comprehensive sequencing of BRCA1 and BRCA2 genes, relevant in hereditary cancer assessment. May be ordered alongside or as an alternative to
81438when broader hereditary cancer risk is evaluated.
- Used for comprehensive sequencing of BRCA1 and BRCA2 genes, relevant in hereditary cancer assessment. May be ordered alongside or as an alternative to
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81213- BRCA1, BRCA2 gene analysis, known familial variants- Used when a specific familial BRCA variant is known. Can be part of a hereditary cancer panel, but is more targeted than
81438.
- Used when a specific familial BRCA variant is known. Can be part of a hereditary cancer panel, but is more targeted than
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81432- Hereditary breast cancer-related disorders, genomic sequence analysis panel- A panel for hereditary breast cancer risk, often used in conjunction with or as an alternative to
81438depending on clinical suspicion.
- A panel for hereditary breast cancer risk, often used in conjunction with or as an alternative to
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81433- Hereditary breast cancer-related disorders, duplication/deletion analysis panel- Focuses on duplication/deletion analysis for breast cancer-related genes, similar in methodology to
81438but for a different clinical indication.
- Focuses on duplication/deletion analysis for breast cancer-related genes, similar in methodology to
These codes are related through their use in hereditary cancer and tumor disorder evaluation. 81438 is specific to neuroendocrine tumor disorders, while the others focus on breast cancer risk. Panels may be ordered together or separately based on patient history and clinical presentation.
National Reimbursement Benchmarks
National mean rates for CPT code 81438 show that UnitedHealth Group has the highest average reimbursement at $783.02, followed by Cigna at $641.89, BUCA (average commercial) at $495.88, and Blue Cross Blue Shield at $401.98. Medicare rates are not available in the input, so a direct comparison to commercial averages cannot be made.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Blue Cross Blue Shield has the tightest range at $132.00, indicating more consistent rates. Cigna's range is $55.50, also showing limited variability. In contrast, UnitedHealth Group exhibits the widest dispersion at $782.50, reflecting substantial variability in rates. BUCA's range is $267.50, which is moderate compared to the others.
The table and chart below present the full breakdown of national benchmarks for CPT code 81438 across major commercial payers.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.