CPT 81454 Reimbursement & Benchmarks | OpenPayer

Summary & Overview

CPT 81454: Targeted Genomic Sequence Analysis Panel for Solid Organ Neoplasms

CPT code 81454 represents a targeted genomic sequence analysis panel for solid organ neoplasms, analyzing DNA from 5 to 50 genes. This advanced laboratory procedure is pivotal in oncology, offering precise genetic insights that inform diagnosis, prognosis, and personalized treatment plans for patients with cancers such as lung, breast, colon, prostate, and pancreas. The code is primarily utilized in independent laboratory settings, reflecting the growing role of molecular pathology in cancer care.

Blue Cross Blue Shield is a key payer covering this service, highlighting its national relevance and widespread adoption. Readers will gain an understanding of the clinical context for 81454, including its application in cancer diagnostics, typical laboratory workflow, and associated billing practices. The publication also provides benchmarks and policy updates relevant to pathology and laboratory services, helping stakeholders stay informed about evolving trends in genomic testing.

This summary offers a comprehensive overview of 81454, its significance in modern oncology, and the payer landscape, equipping healthcare professionals, administrators, and policy analysts with essential information for decision-making and operational planning.

Blue Cross Blue ShieldCPT 81454genomic sequencingsolid organ neoplasmpathologylaboratory medicinecancer diagnosticsmolecular pathologyindependent laboratoryoncologyDNA analysis

CPT Code Overview

CPT code 81454 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 an Independent Laboratory setting (Place of Service 81). This code enables clinicians to obtain detailed genetic profiles of tumors, supporting personalized treatment strategies and improving patient outcomes.

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 requests DNA analysis of 5-50 genes to identify mutations relevant for prognosis or targeted therapy. The specimen is sent to an independent laboratory (Place of Service 81), where a pathologist specializing in molecular genetic pathology oversees the testing. The results inform treatment decisions, such as eligibility for targeted therapies or clinical trials.

Coding Specifications

Modifiers:
- Modifier 26: Used when billing for the professional component, which includes interpretation and reporting by the pathologist.
- Modifier TC: Used when billing for the technical component, which covers the laboratory processing and analysis of the specimen.
Provider Taxonomies:

Taxonomy Code Specialty Name
207ZP0102X

Taxonomy Code	Specialty Name
`207ZP0102X`

National Reimbursement Benchmarks

Nationally, Blue Cross Blue Shield and BUCA (average commercial) both reimburse CPT code 81454 at a mean rate of $80.02. Medicare rates are not available in the input for comparison. The mean rates for these commercial payers are identical, indicating uniformity in national pricing for this code.

Rate dispersion is minimal across both Blue Cross Blue Shield and BUCA, with the 25th, 50th, and 75th percentiles all at $80.00. This tight range suggests little variation in reimbursement rates among providers for these payers. The table and chart below present the full breakdown of national benchmarks for CPT code 81454.

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*)

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

81429-GENOMIC-SEQUENCE-ANALYSIS-PANEL-SOLID-ORGAN-NEOPLASM-DNA

CPT 81429: Genomic Sequence Analysis Panel for Solid Organ Neoplasms

81438-HEREDITARY-NEUROENDOCRINE-TUMOR-DISORDERS

CPT 81438: Genomic Sequencing for Hereditary Neuroendocrine Tumor Disorders