Summary & Overview
CPT 81163: BRCA1 and BRCA2 Full Gene Sequencing
CPT code 81163 represents full-gene sequencing of the BRCA1 and BRCA2 genes performed by a laboratory analyst. These assays identify pathogenic and likely pathogenic variants associated with hereditary breast and ovarian cancer syndromes, influencing clinical risk assessment, genetic counseling, and treatment planning. Nationally, BRCA sequencing is a high-impact diagnostic service due to its implications for preventive interventions, targeted therapies, and family cascade testing.
Key payers commonly involved in coverage and reimbursement discussions include Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Coverage policies and prior authorization requirements vary by payer and by medical necessity criteria.
Readers will find an overview of the service and clinical context, a summary of major payers that typically cover this molecular test, and the scope of what the code denotes. The publication also provides benchmarks and policy-relevant points to inform billing, coding, and payer communications, as well as references to where to locate payer-specific coverage policies and clinical guidelines. Data not available in the input is identified where relevant.
Billing Code Overview
CPT code 81163 describes a laboratory service in which the lab analyst performs the technical testing necessary to analyze the entire gene sequence for the BRCA1 DNA repair–associated gene and the BRCA2 DNA repair–associated gene. This service is a full-sequence molecular diagnostic assay for the BRCA1 and BRCA2 genes.
Service type: Molecular diagnostic laboratory testing (full gene sequencing)
Typical site of service: Clinical molecular diagnostics laboratory or commercial reference laboratory
Clinical & Coding Specifications
Clinical Context
A 42-year-old woman with a family history of early-onset breast cancer is referred by her breast surgeon for comprehensive hereditary cancer testing. The clinician documents a detailed genetic counseling discussion and orders full gene sequencing for both BRCA1 and BRCA2 to evaluate for pathogenic variants that alter DNA repair and increase lifetime risk for breast and ovarian cancer. A peripheral blood sample (or saliva specimen) is collected in the outpatient phlebotomy lab and sent to a molecular diagnostics laboratory. The lab analyst performs the technical sequencing and bioinformatic analysis of the entire coding regions and selected intronic regions of BRCA1 and BRCA2, generating a laboratory report with variant classification. Results are routed to the ordering clinician and genetic counselor for interpretation and patient management planning. Typical site of service is an outpatient molecular diagnostics laboratory or hospital-based reference laboratory. Typical service type is clinical laboratory molecular pathology/genetic testing.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 |