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    v1.0.30
    OpenPayerBilling CodesTier 2 Molecular Pathology ProceduresCPT cpt-81403-tier-2-level-4-molecular-pathology-technical
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    CPT 81403: Molecular Pathology Technical Component, Tier 2 Level 4

    Commercial payers pay $246 on average nationally for this procedure.

    CPT code 81403 describes a Tier 2, Level 4 molecular pathology technical service in which a laboratory analyst performs the technical laboratory testing required to complete a specified genetic analysis; service type: molecular pathology technical component; typical site of service: clinical laboratory or hospital laboratory performing molecular diagnostic testing.

    For related coverage guidance, see recent payer policy updates: Oral Cancer Screening and Testing, RTM Testing for Alpha-1 Antitrypsin Deficiency, Cytochrome P450 Genotype-Guided Treatment Strategy Corporate Medical Policy.

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    National Reimbursement Benchmarks

    Commercial rates for CPT 81403 show meaningful variation around the BUCA average commercial rate of $246.00. Blue Cross Blue Shield exhibits the highest dispersion (P75 $337.60 minus P25 $226.80 = $110.80), indicating broader negotiated outcomes, while Aetna’s interquartile spread is tighter (P75 $148.20 minus P25 $60.00 = $88.20) relative to BCBS and Cigna. UnitedHealth Group has the narrowest IQR (P75 $185.20 minus P25 $77.80 = $107.40) — slightly wider than Aetna on absolute dollars but smaller compared with BCBS’s large spread when considering its high upper percentiles.

    Looking at central tendency, Cigna’s median of $172.10 and UnitedHealth Group’s median of $111.10 flank the BUCA average, suggesting BUCA sits above some major payers’ midpoints. Blue Cross Blue Shield’s high dispersion plus a median of $265.40 points to more upward variability in contracted rates, while Aetna’s statistics reflect a lower median of $100.00 with a comparatively modest IQR.

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A 28-year-old patient is referred to a clinical laboratory after an abnormal prenatal screen and a family history of a hereditary metabolic disorder. The clinician orders a targeted molecular pathology test to evaluate a specific gene or set of exons for sequence variants and copy-number changes. The laboratory technologist performs the technical assay described by 81403—a Tier 2, Level 4 molecular pathology procedure—processing the specimen (blood or cultured cells), running the molecular analysis (for example, targeted DNA sequencing or deletion/duplication testing of a single gene region), and producing the raw technical data. The typical workflow includes specimen receipt and accessioning, DNA extraction, library preparation or targeted amplification, instrument run, primary data generation, and technical result reporting to the laboratory director. The professional component (interpretation and final sign-out) may be reported separately by a board-certified clinical molecular pathologist or geneticist using an appropriate professional CPT code or modifier. Typical site of service is a referenced clinical laboratory or hospital laboratory with molecular pathology capabilities. Common clinical indications include screening for chromosomal anomalies (Z13.79), evaluation of an unspecified chromosomal abnormality (Q99.9), investigation of a suspected metabolic disorder (E88.9), follow-up of abnormal urine findings (R82.90), or assessment after abnormal cardiovascular testing (R94.39).

    Related CPT Codes

    CPT Code

    Related Modifiers

    7 rows

    ModifierDescriptionWhen to Use
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    90Modifier ‑90 (Reference/Outside Laboratory) indicates that a laboratory test was performed by an entity other than the treating or reporting provider. The American Medical Association defines…- Use CPT modifier -90 when a laboratory test is performed by an outside/reference laboratory (an entity other than the treating or reporting physician or qualified professional) and the claim needs…
    91Modifier 91 — “Repeat Clinical Diagnostic Laboratory Test” — is appended when the exact same CPT laboratory test is performed more than once for the same patient on the same day because serial,…- Use modifier 91 when the exact same CPT laboratory test is performed more than once on the same patient on the same date because serial or repeated testing is medically necessary to monitor…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207ZP0102X
    207L00000X
    207Q00000X
    207R00000X
    208D00000X
    174M00000X
    133VN1004X
    363LP0808X

    Related Payer Policy Updates

    Specialty: Genetic & Molecular Testing1 / 2

    10 rows

    PolicyPayerEffective Date
    Oral Cancer Screening and TestingOscar Health2027-01-01
    RTM Testing for Alpha-1 Antitrypsin DeficiencyOscar Health2027-01-01
    Cytochrome P450 Genotype-Guided Treatment Strategy Corporate Medical Policybcbsvermont2027-01-01
    Carrier Testing Panels for Genetic Diseases (for Kentucky Only)UnitedHealthcare2026-10-01
    Genetic Testing for Neurological Disorders (for Kansas Only)UnitedHealthcare2026-10-01
    Genetic and Molecular TestingProvidence Health Plan2026-10-01
    Cell-Free Fetal DNA Testing (for Idaho Only)UnitedHealthcare2026-10-01
    Next Generation Sequencing for Minimal Residual Disease DetectionProvidence Health Plan2026-10-01
    Pharmacogenetic Panel Testing (for Kansas Only)UnitedHealthcare2026-10-01
    Non-Covered Genetic Panel TestsProvidence Health Plan2026-10-01

    Related Codes

    CPT-81400-MOLECULAR-PATHOLOGY-TECHNICAL-LAB-PROCEDURE

    CPT 81400: Molecular Pathology Tier 2, Level 1 Technical Test

    CPT-81401-MOLECULAR-PATHOLOGY-TECHNICAL-LAB-ANALYSIS

    CPT 81401: Tier 2, Level 2 Molecular Pathology Technical Test

    CPT-81402-MOLECULAR-PATHOLOGY-LEVEL-3-TECHNICAL-TEST

    CPT 81402: Molecular Pathology Tier 2 Level 3 Technical Test

    CPT-81404-TIER-2-MOLECULAR-PATHOLOGY-TECHNICAL-COMPONENT

    CPT 81404: Molecular Pathology Technical Laboratory Procedure

    CPT-81405-MOLECULAR-PATHOLOGY-TECHNICAL-LAB-TESTING

    CPT 81405: Tier 2 Level 6 Molecular Pathology Lab Test

    CPT-81406-MOLECULAR-PATHOLOGY-TECHNICAL-LAB-ANALYSIS

    CPT 81406: Molecular Pathology Tier 2, Level 7 Technical Component

    CPT-81407-TIER-2-LEVEL-8-MOLECULAR-PATHOLOGY-TECHNICAL-TEST

    CPT 81407: Technical Molecular Pathology Lab Test

    CPT-81408-MOLECULAR-PATHOLOGY-TECHNICAL-TIER-2-LEVEL-9

    CPT 81408: Tier 2 Molecular Pathology Technical Laboratory Analysis

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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    Description
    Relationship to This Procedure
    81404Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis)Higher-level Tier 2 molecular pathology code used when the assay scope includes more exons or additional analytic complexity than 81403; may be billed when the laboratory performs a more extensive targeted analysis