CPT 81452 Reimbursement & Benchmarks | OpenPayer

Summary & Overview

CPT 81452: Targeted Genomic Sequence Analysis Panel for Solid Organ Neoplasms

CPT code 81452 represents targeted genomic sequence analysis panels for solid organ neoplasms, analyzing DNA from 5 to 50 genes. This advanced laboratory procedure is pivotal in oncology, offering clinicians detailed genetic insights that inform diagnosis, prognosis, and personalized treatment plans for cancer patients. The code is widely recognized in national billing and reimbursement frameworks, reflecting the growing importance of molecular diagnostics in cancer care.

Key payers covered in this publication include Blue Cross Blue Shield, highlighting payer policies and coverage trends relevant to this code. Readers will gain an understanding of clinical benchmarks, policy updates, and the broader context of genomic testing in pathology and laboratory services. The publication also addresses common billing modifiers, associated physician taxonomies, and relevant ICD-10 diagnoses, providing a comprehensive overview for stakeholders in medical billing, laboratory operations, and oncology practice.

This summary offers a clear perspective on the role of 81452 in advancing precision medicine, its impact on payer coverage, and its integration into laboratory workflows. The information is designed to support healthcare professionals, administrators, and policy analysts seeking to stay informed about evolving standards in cancer genomics and laboratory billing.

Blue Cross Blue ShieldCPT 81452genomic sequencingsolid organ neoplasmpathologylaboratoryoncologyprecision medicinemedical billingcancer diagnosticspolicy update

CPT Code Overview

CPT code 81452 is used for targeted genomic sequence analysis panels focused on solid organ neoplasms. This procedure involves DNA analysis of 5 to 50 genes, providing critical information for the diagnosis and management of various cancers. The service is classified under Pathology and Laboratory, and is typically performed in a laboratory setting (Place of Service 81). This code enables clinicians to obtain detailed genetic profiles of tumors, supporting personalized treatment strategies and advancing precision medicine in oncology.

Clinical & Coding Specifications

Clinical Context

A patient diagnosed with a solid organ neoplasm, such as lung, breast, colon, prostate, or pancreatic cancer, is referred for targeted genomic sequence analysis. The ordering physician, typically a medical oncologist or pathologist, requests a panel to analyze DNA from the tumor tissue for mutations in 5-50 genes relevant to the cancer type. The specimen is sent to a laboratory (Place of Service 81), where the test is performed. Results are used to guide prognosis, treatment selection, or eligibility for targeted therapies.

Coding Specifications

Modifiers:
- Modifier 26: Used when reporting only the professional component (interpretation of results) of the procedure.
- Modifier TC: Used when reporting only the technical component (performance of the test in the laboratory).
Provider Taxonomies:

Code Specialty Name
207ZP0102X

Code	Specialty Name
`207ZP0102X`

National Reimbursement Benchmarks

For CPT code 81452, the national mean rate for Blue Cross Blue Shield and BUCA (average commercial) is $80.02. Medicare rates are not available in the input for this code, so a direct comparison between commercial and Medicare rates cannot be made.

Rate dispersion across all payers is extremely tight, with the 25th, 50th, and 75th percentiles all at $80.00 for Blue Cross Blue Shield and BUCA. This indicates no variation in rates among these commercial payers. No data is available for Aetna, Cigna, UnitedHealth Group, or Medicare.

The table and chart below present the full breakdown of national mean rates and percentile values for each payer.

81416 – CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *7, *8, *17)

81411-APOLIPOPROTEIN-E-APOE-GENE-ANALYSIS-COMMON-VARIANTS-EG-E2

81411 – Apolipoprotein E (ApoE) gene analysis, common variants (e.g., *E2, *E3, *E4*)

81456-GENOMIC-SEQUENCE-ANALYSIS-PANEL-EG-TUMOR-OR-BONE-MARROW-RNA

81456 – Genomic sequence analysis panel (e.g., tumor or bone marrow), RNA alterations, 51 or more genes

81410-GENOMIC-SEQUENCING-PROCEDURE-HERITABLE-THORACIC-AORTIC

CPT 81410: Genomic Sequencing for Heritable Thoracic Aortic Disease

81408-TIER-2-MOLECULAR-PATHOLOGY-PROCEDURES-LEVEL

CPT 81408: Advanced Molecular Pathology Laboratory Procedure

81477-MOLECULAR-PATHOLOGY-PROCEDURE-LEVEL-9-EG-ANALYSIS-OF-1125

CPT 81477: Molecular Pathology Procedure, Level 9 DNA Sequence Analysis

81438-HEREDITARY-NEUROENDOCRINE-TUMOR-DISORDERS

CPT 81438: Genomic Sequencing for Hereditary Neuroendocrine Tumor Disorders