BPI20-025: Aligning Genetic Panel Utilization With Clinical Practice Guidelines Through Education

Background: NGS panel tests can provide the patient clinically actionable data. Unfortunately, contrary to AMA guidelines, many labs have continued to either stack or unbundle the individual test codes which may result in increased reimbursement at the expense of patients and payers rather than use an AMA-issued procedure code for the gene panel test. The objective of this study is to gauge how education and quality assurance (QA) processes affect correct implementation of clinical practice coding guidelines. Methods: Administrative prior authorization data were collected from Avalon Healthcare Solutions network providers over an 18-month period (01/01/2018-8/30/2019). Data were further restricted to a single network provider conducting gene panel testing to demonstrate the course of change in sequencing ordering over time from education and QA processes. Descriptive statistics were conducted for the single network provider, and service unit utilization was tracked over the 18-month period by procedure code. Results: Among the total cohort, 6559 service units were performed between 1/1/2018 and 8/30/2019 with procedure code 81162, 81211, 81213, 81432, or 81433. Of the total service units, 4248 (64.8%) were paid, and 2311 (35.2%) were denied. In total, 1893 (28.9%) units of procedure code 81211 and 1937 (29.5%) units of procedure code 81213 (both retired in 2019), 1937 (29.5%) units of procedure code 81432, 1137 (17.3%) units of procedure code 81433, and 446 (6.8%) units of procedure code 81162 were performed. Over the course of this study, utilization by approved units of genetic sequencing before and after the retirement of codes 81211 and 81213 is comparable. A decrease in utilization of code 81162 occurs over the course of education with a subsequent increase in the uses of codes 81432 and 81433. Further, the denial disposition breakdown shows that denials are due primarily to lack of medical necessity (86.8%), and thereby not from inappropriate filing or administrative reasons. Conclusions: Education and QA processes can positively redirect providers and laboratories to follow AMA coding practice guidelines while providing patients with clinically appropriate genetic testing without increasing coverage denials due to inappropriate filing or other administrative reasons. Therefore, trends in decrease denials can be attributed to education and QA measures, ensuring correct coding and medical necessity as described by medical policy.

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Corresponding Author: Jeremy J. Day-Storms, PhD, MA
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