Summary & Overview
CPT 0220U: PreciseDx Breast Cancer Test, Recurrence Score
CPT code 0220U identifies the PreciseDxTM Breast Cancer Test, a proprietary laboratory analysis that uses image analysis and artificial intelligence to evaluate 12 tumor features and produce a recurrence score. As a PLA code, 0220U applies to a single manufacturer’s test and signals a specialized diagnostic service increasingly relevant for personalized oncology care. Nationally, such PLA codes are important for payer coverage decisions, precision-medicine workflows, and lab reimbursement policy.
Key payers reviewed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of payer coverage landscapes, common billing modifiers, and the clinical context for test use. The publication summarizes benchmarks for utilization and reimbursement where available, highlights policy and coding considerations specific to PLA codes, and explains implications for laboratory operations and oncology care teams. The content aims to help billing leads, laboratory directors, and policy analysts understand how CPT code 0220U is used, where it is performed, and what stakeholders consider when evaluating coverage for proprietary diagnostic tests.
Billing Code Overview
CPT code 0220U is a Proprietary Laboratory Analyses (PLA) code for the PreciseDxTM Breast Cancer Test. The test uses image analysis and artificial intelligence to evaluate 12 features in a breast tumor sample and generate a recurrence score to inform prognosis and potential treatment planning.
Service Type: Laboratory — proprietary molecular/diagnostic test using image analysis and AI
Typical Site of Service: Independent clinical laboratory or hospital-based pathology laboratory (specimen sent to the performing lab)
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 58-year-old woman with early-stage, estrogen receptor–positive invasive breast carcinoma undergoes primary lumpectomy. The pathology report confirms a tumor specimen submitted for histologic review and formalin-fixed paraffin-embedded (FFPE) block selection. The treating surgical oncologist orders the PreciseDxTM Breast Cancer Test to assess the tumor’s recurrence risk using image analysis and artificial intelligence evaluating 12 morphological and spatial features. The lab receives the selected FFPE slide, performs digital scanning and algorithmic analysis, and returns a quantitative recurrence score to the ordering oncologist and multidisciplinary tumor board to inform adjuvant therapy planning. Typical site of service is an outpatient hospital or independent clinical laboratory with pathology and digital imaging capability. The specimen acquisition occurs in the operating room or outpatient surgery center; testing and analysis occur in the clinical laboratory or specialty molecular pathology facility.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | No modifier — default reporting | Use when no specific modifier applies to the laboratory proprietary test billing. |
26 | Professional component | Use when billing physician interpretation/reporting separately from the technical component. |
TC | Technical component | Use when billing the technical component (laboratory processing, scanning, algorithmic analysis) separately. |
52 | Reduced services | Use when the test is partially performed or yields partial results due to specimen limitations. |
53 | Discontinued procedure | Use if testing was begun but discontinued for valid clinical or specimen reasons. |
59* | Distinct procedural service | Not in provided list; therefore Data not available in the input. |
QX | Ordering/servicing laboratory modifier (modifier QX) | Use when the lab performing the test is the clinical laboratory that both ordered and performed the test per payer rules (where applicable). |
QY | Ordering/performing provider (modifier QY) | Use when the supplier is the ordering provider of the diagnostic service according to payer policy. |
FY | Patient’s incapacity to sign or special circumstances | Use when unique administrative circumstances related to specimen consent apply (lab-specific billing scenarios). |
SH | Surgical assistant billing | Use if an assistant surgeon separately bills for surgical specimen procurement services (rare for lab-only PLA reporting). |
AS | Physician service billed under anesthesia plan | Use when applicable for anesthesia-related billing tied to specimen acquisition (rare). |
| Taxonomy Code | Specialty | Notes |
|---|---|---|
| 2085R0200X | Pathology | Surgical pathologists and molecular pathologists who oversee specimen processing and interpretation. |
| 207Q00000X | Anatomic Pathology | Providers specializing in anatomic pathology integrate histology selection and slide preparation. |
| 207L00000X | Laboratory Director | Clinical laboratory directors who manage PLA testing workflows and CLIA compliance. |
| 2084P0800X | Hematology/Oncology | Medical oncologists who order the test to guide adjuvant therapy decisions. |
*Note: Modifier 59 was not included in the provided modifier list; only modifiers from the input were used where applicable. Where a provided modifier has limited applicability to a PLA lab test, the most relevant administrative or billing scenarios were described.
Related Diagnoses
| ICD-10 Code | Description | Clinical Relevance |
|---|---|---|
C50.911 | Malignant neoplasm of unspecified site of right female breast | Common diagnosis for which tumor tissue is submitted for recurrence risk testing. |
C50.912 | Malignant neoplasm of unspecified site of left female breast | As above for left-sided tumors; guides adjuvant therapy decisions informed by recurrence score. |
C50.121 | Malignant neoplasm of central portion of right female breast | Specific tumor location codes used on pathology and billing when submitting specimens for PLA testing. |
C50.122 | Malignant neoplasm of central portion of left female breast | Location-specific code used with specimen submission and clinical correlation. |
D05.10 | Lobular carcinoma in situ of unspecified breast | In select cases, sampling and further risk assessment may drive additional testing decisions. |
D05.90 | Unspecified type of carcinoma in situ of breast | May be present in surgical specimens requiring additional characterization prior to adjuvant planning. |
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|---|---|
88185 | Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain | Performed on surgical specimens when ancillary stains are needed to characterize tumor markers before or alongside PLA testing. |
88305 | Level IV surgical pathology, gross and microscopic examination | Typical pathology report coding for tumor resection that yields the specimen sent for the PreciseDxTM assay. |
88342 | Immunohistochemistry for multiple antibodies (per slide or per panel) | Used when panels of IHC are run to determine receptor status that complements AI-derived recurrence assessment. |
84999 | Unlisted chemistry procedure | Occasionally used by payers if a PLA lacks direct reimbursement linkage; administrative use varies by payer. |
0438U | Molecular pathology procedure (example PLA) | Representative PLA-type code for other proprietary molecular/AI assays; indicates similar billing context and payer review processes. |