Summary & Overview
CPT 81554: mRNA Gene Expression Profiling for Usual Interstitial Pneumonia
CPT code 81554 covers an mRNA-based molecular diagnostic test performed on a transbronchial biopsy specimen that analyzes expression of 190 genes and applies an algorithm to produce a categorical result indicating a high probability of usual interstitial pneumonia (UIP). This test supports diagnostic evaluation in patients with suspected interstitial lung disease and can affect downstream clinical decision pathways, including specialist referral and management planning.
Key payers in the national analysis include Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for the test, the types of services and sites where it is performed, and typical payer coverage considerations. The publication summarizes available benchmarks and payment policy themes relevant to advanced molecular diagnostics, highlights common billing modifiers and administrative considerations, and outlines clinical implications tied to the reported categorical result.
The content is intended to inform health plan managers, laboratory directors, coding and billing staff, and clinicians about the scope and purpose of CPT code 81554, expected service setting, and the kinds of policy and billing issues that typically accompany high-complexity molecular algorithmic testing.
Billing Code Overview
CPT code 81554 describes a laboratory service in which a lab analyst performs mRNA gene expression profiling on a transbronchial biopsy specimen for a panel of 190 genes and applies an algorithmic analysis using patient data and test results to report a categorical result: positive or negative for a high probability of usual interstitial pneumonia (UIP).
Service Type: Molecular diagnostic laboratory test with algorithmic result reporting
Typical Site of Service: Clinical laboratory or pathology laboratory receiving transbronchial biopsy specimens
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient with progressive exertional dyspnea, nonproductive cough, and bibasilar inspiratory crackles undergoes evaluation for suspected interstitial lung disease (ILD). High-resolution chest CT demonstrates peripheral and basal-predominant reticular opacities with possible honeycombing but an indeterminate pattern for usual interstitial pneumonia (UIP). After multidisciplinary discussion between pulmonology, thoracic surgery, and pathology, a bronchoscopy with transbronchial biopsy is performed to obtain tissue for molecular testing. The specimen is sent to a molecular diagnostics laboratory where the lab analyst performs mRNA gene expression profiling on the transbronchial biopsy for a 190-gene panel and runs the algorithmic analysis that integrates patient data and test results to generate a categorical report (positive or negative) for high probability of UIP. Typical workflow steps: pre-procedure consent and imaging review by pulmonology; bronchoscopy with biopsy in an endoscopy suite or operating room; specimen handling and shipment to a reference molecular lab; laboratory technical processing, quality control, algorithmic analysis, and final result reporting to the ordering clinician. Typical site of service: hospital outpatient endoscopy suite, ambulatory surgical center, or specialized molecular pathology laboratory receiving the biopsy specimens.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | (Not a standard CMS modifier; used as placeholder in raw data) | Data not available in the input for clinical use; do not apply clinically. |