CPT 81202 APC Familial Mutation Reimbursement

CPT code 81202 denotes a targeted laboratory assay to detect familial mutations in the adenomatous polyposis coli (APC) gene. This CPT genetic test is used when a known familial APC mutation is suspected and a focused analysis for that specific mutation is appropriate. Clinically, identification of a familial APC mutation has implications for hereditary colorectal cancer syndromes and cascade testing of at-risk relatives.

Nationally, CPT code 81202 matters because it supports precision testing strategies that can reduce turnaround time and cost compared with full-gene sequencing when a familial variant is known. Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. These payers commonly establish coverage policies that distinguish targeted familial testing from broad hereditary cancer panels.

Readers will find context on the clinical purpose of the code, typical settings in which the service is delivered, and which major payers are relevant. The publication outlines what stakeholders can expect to see in payer coverage frameworks, common billing considerations, and how CPT code 81202 fits within the broader molecular diagnostics service line. Data not available in the input will be noted where applicable.

Billing Code Overview

CPT code 81202 describes a laboratory genetic test performed by a lab analyst to detect the presence of mutations in the adenomatous polyposis coli (APC) gene that are common to the patient’s family members. This is a targeted familial mutation analysis rather than a broad sequencing assay.

Service type: Targeted familial genetic testing
Typical site of service: Clinical laboratory or molecular diagnostics laboratory (laboratory/ambulatory reference lab)

Data not available in the input.

Clinical Context

A typical patient is an adult with a family history of familial adenomatous polyposis (FAP) or an identified pathogenic APC variant in a relative who presents for targeted genetic testing. The clinical workflow begins with genetic counseling that documents family history and the specific APC variant identified in an affected family member. A referral to a clinical genetics laboratory is placed, and a blood or saliva specimen is collected in the outpatient laboratory or clinic setting. The laboratory performs targeted molecular testing to detect the known familial APC mutation. Results are reported to the ordering clinician and genetic counselor, who review implications for cancer surveillance, prophylactic surgery, and cascade testing of at-risk relatives. Typical site of service is an outpatient genetics clinic or an independent clinical molecular diagnostics laboratory; specimen collection often occurs at an ambulatory clinic, physician office, or hospital outpatient phlebotomy center.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the professional interpretation component separate from the technical laboratory processing, if applicable.
`TC`	Technical component

Taxonomy Code	Specialty	Notes
`207R00000X`	Medical Genetics	Clinical geneticists order and interpret APC targeted testing and manage cascade testing plans.
`208D00000X`	Diagnostic Molecular Pathology	Laboratory molecular pathologists oversee technical assay validation and result interpretation.
`207K00000X`	Genetic Counseling	Certified genetic counselors obtain family history, provide pre/post-test counseling, and coordinate testing.
`207L00000X`	Pediatric Genetics	Used when pediatric patients are tested due to early-onset polyposis in family members.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z15.0`	Genetic susceptibility to malignant neoplasm of digestive organs	Used for patients with known familial risk such as a familial APC mutation prompting targeted testing.
`K63.5`	Polyp of colon	Relevant when a patient has colonic polyps suggestive of familial adenomatous polyposis and genetic confirmation is sought.
`Z80.0`	Family history of malignant neoplasm of digestive organs	Used when there is a family history of colorectal cancer prompting APC targeted testing.
`Z84.81`	Family history of carrier of genetic disease	Applied when testing is performed to determine carrier status or familial pathogenic variant status.
`Z13.79`	Encounter for screening for other suspected genetic disorders	Used for asymptomatic relatives undergoing targeted testing because of an identified familial APC variant.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`81202`	APC (adenomatous polyposis coli) gene; targeted analysis for known familial variants	Primary code describing the technical laboratory assay to detect the family-specific APC mutation.
`81211`	APC (adenomatous polyposis coli) gene; full gene sequencing	Performed when no known familial mutation exists and comprehensive sequencing of APC is required for diagnosis.
`81162`	Targeted genomic sequence analysis (e.g., known familial single gene variant)	Often used for other single-gene targeted familial variant tests; conceptually similar when reporting targeted analyses for known variants.
`81479`	Unlisted molecular pathology procedure	Used for novel or non-standard molecular tests not described by existing CPT codes when necessary.
`81432`	Hereditary colorectal cancer syndromes panel (multiple genes)	Performed when broader multi-gene panel testing for hereditary colorectal cancer is indicated beyond the single APC familial variant.

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Summary & Overview

CPT 81202: Targeted Familial APC Mutation Analysis