CPT 81507 NIPS Trisomy Reimbursement & Policy | OpenPayer

Summary & Overview

CPT 81507: Non-Invasive Prenatal Screening for Trisomies 13, 18, 21

CPT code 81507 represents a laboratory-based non-invasive prenatal screening (NIPS) test that analyzes cell-free fetal DNA in maternal plasma to assess risk for trisomies 13, 18, and 21. This analytic service combines micro assay techniques with algorithmic interpretation to generate individualized risk scores, informing prenatal risk assessment and clinical decision-making. Nationally, such molecular diagnostic tests are increasingly integrated into prenatal care pathways because they offer high sensitivity and specificity for common aneuploidies while avoiding invasive procedures.

Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for use of CPT code 81507, common coverage considerations from major payers, and the types of benchmarks and policy updates that affect laboratory reimbursement and utilization management. The publication summarizes service definitions, typical sites of service, and implementation considerations relevant to laboratory administrators, payers, and clinicians. Data not provided in the input are noted as unavailable where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare81507CPTnon-invasive prenatal screeningcell-free DNAmaternal plasmatrisomy screeningmolecular diagnosticslaboratory services

Billing Code Overview

CPT code 81507 describes a laboratory analytic service that detects fetal trisomies 13, 18 and 21 from maternal plasma during pregnancy. The service involves performing technical laboratory assays using a micro assay technique and applying an algorithmic analysis that combines patient data with lab test results to report a patient-specific risk score for each trisomy.

Service type: Non-invasive prenatal screening (laboratory-based molecular diagnostic test)
Typical site of service: Clinical laboratory or diagnostic laboratory setting; specimen collected in an outpatient or ambulatory setting and analyzed in a laboratory.

Clinical & Coding Specifications

Clinical Context

A 34-year-old pregnant patient at 10–22 weeks gestation presents for prenatal screening after routine obstetric counseling. The clinician orders a maternal plasma cell-free DNA (cfDNA) noninvasive prenatal screening test to assess risk for fetal trisomy 13, trisomy 18, and trisomy 21. A phlebotomy draw is performed in the outpatient obstetrics clinic or an affiliated laboratory collection center; the specimen is sent to a reference laboratory where a molecular lab analyst performs microassay testing and algorithmic analysis of fetal cfDNA present in maternal plasma. The lab generates and reports a patient-specific risk score for each trisomy to the ordering provider. Typical sites of service are outpatient obstetrics/gynecology clinics, prenatal diagnostic centers, and independent clinical reference laboratories. The clinical workflow includes patient counseling, informed consent for prenatal screening, specimen collection and shipment, laboratory analytic processing (sequencing or microassay), bioinformatic algorithmic interpretation, and result reporting to the ordering clinician for follow-up counseling and possible diagnostic testing (e.g., chorionic villus sampling or amniocentesis) if high risk is reported.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the professional (interpretation) component provided by a pathologist or laboratory director distinct from the technical processing.

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Taxonomy Code	Specialty	Notes
207Q00000X	Obstetrics & Gynecology	Ordering and counseling providers who routinely request prenatal cfDNA screening.
207L00000X	Maternal-Fetal Medicine	Specialists managing high-risk pregnancies and follow-up diagnostic testing for abnormal screening.
207RH0000X	Reproductive Endocrinology	Providers involved when prenatal genetic screening occurs in assisted reproduction contexts.
207K00000X	Clinical Genetics	Genetic counselors and clinical geneticists who interpret risk scores and advise on confirmatory testing.
362M00000X	Phlebotomy & Laboratory Collections	Personnel who perform specimen collection and handling prior to reference lab processing.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`Z34.90`	Encounter for supervision of normal pregnancy, unspecified, unspecified trimester	Common screening context for prenatal cfDNA in routine prenatal care.
`Z36.89`	Encounter for other fetal assessment	Represents encounters for targeted fetal screening including cfDNA testing.
`O09.89`	Supervision of pregnancy with other known or suspected fetal problems, not elsewhere classified	Used when pregnancy is being monitored for suspected fetal chromosomal issues.
`Z31.69`	Encounter for other genetic counseling and testing	Used when documenting genetic counseling and decision-making related to cfDNA screening.
`O00.9`	Ectopic pregnancy, unspecified	Included to document alternative pregnancy complications that may affect interpretation or testing decisions (less common association).
`Z33.1`	Pregnant state	General pregnancy status code often used in documentation surrounding prenatal testing.
`R87.619`	Abnormal findings on fetal heart rate and rhythm study	Represents abnormal prenatal findings that may trigger additional screening including cfDNA (contextual relevance).

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`81025`	Urinalysis; automated with microscopy	Performed at initial prenatal visit to assess maternal health prior to screening; not directly part of cfDNA testing but commonly ordered in the same prenatal workup.
`36415`	Collection of venous blood by venipuncture	The specimen collection procedure used to obtain maternal plasma for cfDNA testing.
`89290`	Cell-free fetal DNA analysis (noninvasive prenatal testing) sequencing procedure, each chromosome targeted	Related molecular laboratory methodology codes sometimes billed for sequence-based cfDNA testing components when applicable.
`88367`	Microarray analysis, interpretation and report	If a microarray-based platform is used for fetal chromosomal analysis, this code may be used for interpretation in certain lab billing scenarios.
`76942`	Ultrasonic guidance for needle placement (eg, amniocentesis)	May be performed subsequently if a high-risk result prompts diagnostic invasive testing such as amniocentesis.
`59015`	Amniocentesis for chromosomal analysis; diagnostic sampling	Performed when cfDNA screening indicates high risk and confirmatory diagnostic testing is pursued.

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