CurrentAmbetter NevadaPolicy CG.PP.551

Genetic and Molecular Testing Services Payment Policy

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Governs billing and payment requirements for genetic and molecular laboratory testing for Ambetter Nevada members, including coding, documentation, and use of Concert Genetics GTUs; applies to providers submitting claims and prior authorizations for these services.

Policy Summary

PayerAmbetter Nevada

PolicyGenetic and Molecular Testing Services Payment Policy

Policy CodePolicy CG.PP.551

Change TypeMaterial updates requiring GTU use and claim element requirements

Effective Date

Last ReviewFeb 26, 2025

Next Review DateFeb 26, 2025

Key ActionRegister on the Concert Genetics portal and include the appropriate Concert GTU identifier on all claims and prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

Annual Review with minor rewording and updates including vendor name change to 'Concert' and updated code section listings and URL.

Reimbursement section reworded to require all providers billing genetic and molecular testing to include specific claim elements and to bill consistent with delivered test results.

Requirement that laboratories/providers register on the Concert Genetics portal and include the Concert GTU identifier on claims and prior authorization requests.

GTU requiredGTU requirement

Tables 1 & 2Code groups included

One unitUnit limit

Registration requiredPortal registration

Coverage and Billing Criteria

Coverage and billing criteria

Billing and coding requirements that determine payment for genetic and molecular testing services.

Providers must bill for the test performed and as delivered on the test result.

Claims must include ordering and rendering provider information.

Claims must include appropriate and accurate ICD diagnosis codes; header (3-digit) ICD codes may lack necessary specificity and can be denied for insufficient specificity.

Claims must include the date and place of service; place of service codes will distinguish outpatient testing from emergency department or inpatient settings.

Procedure codes must be determined by the attributes of the testing performed (not by clinical indication); use PLA/MAAA/panel codes when assigned and proprietary codes only for the specific test to which they are assigned.

Per NCCI Chapter 10 Section F-8, when one laboratory procedure evaluates multiple genes using a next-generation sequencing procedure, report only one unit of service of one genomic sequencing procedure.

When a procedure consolidates multiple analytes into a single testing process, report only one unit of service of the appropriate level II HCPCS, CPT, or PLA code; if a panel code is not appropriate, a limited number of individual components may be billed.

Only one unit of non-specific procedure codes CPT 81479 and 81599 may be billed per test.

Modifier codes should be used when billing multiple service units is appropriate (e.g., repeat testing, multiple specimens, multiple species); Modifier 52 may be used when interpretation of existing data is billed at an adjusted rate because wet lab procedures were not performed.

Comply with Procedure-to-Procedure (PTP) and Medically Unlikely Edit (MUE) requirements; do not exceed MUE limits where applicable.

Providers and laboratories must register on the Concert Genetics portal to verify their genetic test catalog, access Concert GTUs, and complete a brief quality profile.

The Concert Genetic Testing Unit (GTU) identifier is required in the procedure description of the claim (e.g., 'GTU6V98G' or '6V98G') and must also be added to all prior authorization requests for genetic and molecular testing services.

Bill for services according to the Concert coding engine standards and ensure coding is consistent with AMA CPT guidelines and the NCCI manual.

Codes and Units of Service

Tier 1 CPT CodesCPT

81105-81383

Tier 1 CPT Codes (molecular/genetic testing)

Tier 2 CPT CodesCPT

81400-81408	Tier 2 CPT Codes
81479	Tier 2 CPT Codes

Genomic Sequencing Procedures (GSP) and Other Molecular Multianalyte AssaysCPT

81410-81471

Genomic Sequencing Procedures (GSP) and Other Molecular Multianalyte Assays CPT Codes

Multianalyte Assays with Algorithmic AnalysesCPT

81490-81599

Multianalyte Assays with Algorithmic Analyses CPT Codes

HCPCS CodesHCPCS

HCPCS

HCPCS Codes for Genetic/Molecular Testing

Proprietary Laboratory Analyses (PLA) CodesPLA

PLA	Proprietary Laboratory Analyses (PLA) Codes for Genetic/Molecular Testing

Units of Service Limits — MUEs and One‑Unit Rules

Medically Unlikely Edit (MUE)MUEs define maximum units of service (UOS); units billed must not exceed the maximum UOS per NCCI guidance.

One‑unit reporting for consolidated genomic proceduresPer NCCI Manual Chapter 10 Section F‑8, when one laboratory procedure evaluates multiple genes via NGS, report only one unit of service of one genomic sequencing procedure.

One‑unit reporting for consolidated multi‑analyte proceduresIf a procedure consolidates testing of multiple analytes (e.g., tandem mass spectrometry), report only one unit of service of one appropriate HCPCS/CPT/PLA code.

Single‑unit limit for non‑specific CPTsOnly one unit of the non‑specific procedure codes CPT 81479 and 81599 may be billed per test.

Use of modifiers when multiple units appropriateModifier codes should be used when billing multiple service units is appropriate (e.g., repeat testing, multiple specimens, multiple species); Modifier 52 may be used for adjusted interpretations without wet lab procedures.

Prior Authorization and Provider Requirements

Prior Authorization

Prior authorization must include Concert GTU

All providers requesting prior authorization for genetic and molecular testing services must include the appropriate Concert Genetics GTU descriptor on every prior authorization request.

Register on the Concert portal to access GTUs and verify the test catalog.
Include the Concert GTU identifier (e.g., 'GTU6V98G' or '6V98G') in the prior authorization request procedure descriptor.

Key Definitions

Concert Genetic Testing Unit (GTU) Requirements

DefinitionConcert GTU is a unique identifier for every genetic test used in the procedure description of claims and prior authorizations (examples: '6V98G' or 'GTU-6V98G').

Where to place GTU on electronic professional claimsElectronic Professional (837P): Loop 2400 Segment SV101-7.

Where to place GTU on electronic institutional claimsElectronic Institutional (837I): Loop 2400 Segment SV202-7.

Where to place GTU on paper claimsPaper Professional (CMS-1500): Item/block 19; Paper Institutional (CMS-1450): Item/block 80.

GTU formatInsert the exact GTU or the GTU preceded by 'GTU-' (e.g., 6V98G or GTU-6V98G).

Policy Summary

PayerAmbetter Nevada

PolicyGenetic and Molecular Testing Services Payment Policy

Policy CodePolicy CG.PP.551

Change TypeMaterial updates requiring GTU use and claim element requirements

Effective Date

Last ReviewFeb 26, 2025

Next Review DateFeb 26, 2025

Key ActionRegister on the Concert Genetics portal and include the appropriate Concert GTU identifier on all claims and prior authorization requests.

SourceLink

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