[Date]
[Payer Name]
[Address]
[City, State, Zip code]
RE:
Ensuring Accurate Reimbursement for Cytogenomic Microarray Analysis in 2013 and Beyond
Dear Sir/Madam,
As you may be aware, American Medical Association (AMA) Current Procedural Terminology (CPT®1)
codes 83890–83914 for molecular diagnostic services have been retired as of January 1, 2013. In their
place, the AMA CPT established a new set of molecular pathology (MoPath) codes that laboratories such
as ours will be using to bill for molecular diagnostic tests moving forward. In light of this, [Lab Name]
would like to request clarification on [Payer Name]’s intended process to establish appropriate payment
rates for MoPath codes, in particular the following:
81228 Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of
genomic regions for copy number variants (e.g., Bacterial Artificial Chromosome [BAC] or
oligo-based comparative genomic hybridization [CGH] microarray analysis)
81229 Cytogenomic interrogation of genomic regions for copy number and single nucleotide
polymorphism (SNP) variants for chromosomal abnormalities
These codes are differentiated by the types of genetic variants interrogated – CPT 81228 describes the
use of oligonucleotide probes to detect copy number variants (CNVs), whereas CPT 81229 describes the
former in addition to the use of single nucleotide polymorphism (SNP) probes to determine zygosity
status.
The following clinical vignettes issued by the AMA provide examples of common patient scenarios in
which each type of test/code may be performed/billed2:
CPT
Clinical Vignette
81228 An 18-month–old male presents to his physician with unexplained developmental delay. The
patient has a normal karyotype and his diagnostic evaluation is otherwise unrevealing. A
sample of anticoagulated peripheral blood is submitted to the laboratory for cytogenomic
constitutional (genome-wide) microarray analysis.
81229 A newborn female is determined to have multiple congenital anomalies by the attending
physician. The patient has a normal karyotype and her diagnostic evaluation is otherwise
unrevealing. The parents indicate they are both from the same ethnic background.
A sample of anticoagulated peripheral blood is submitted to the laboratory for cytogenomic
constitutional (genome-wide) microarray analysis.
1
CPT is a registered trademark of the American Medical Association. ©2012 American Medical Association. All
rights reserved.
2
© American Medical Association 2011. All rights reserved.
Background on Cytogenomic Microarray Analysis
Cytogenomic microarray analysis (CMA) can be used to identify large structural variations throughout an
individual’s genome, including single nucleotide polymorphisms (SNPs) and copy number variations
(CNVs) that are linked to genetic disorders.
The American College of Medical Genetics (ACMG) guidelines recommend CMA testing for CNV as a
first-line test in the initial post-natal evaluation of individuals with the following multiple anomalies not
specific to a well-delineated genetic syndrome, apparently nonsyndromic developmental delay and/or
intellectual disability, or autism spectrum disorders3.
Clarifying and Supporting the Rate-Setting Process for Cytogenomic Microarray Analysis
Given the reimbursement uncertainty created by the recent coding changes, [Lab Name] would like to
better understand the process and methodologies that [Payer Name] will employ to identify
reimbursement rates for the cytogenomic microarray analysis codes, as well as the associated timelines.
If permissible, we would also be interested in providing you with the information necessary to support
accurate payment determinations for these codes.
As an example, these are the inputs that Medicare Administrative Contractors (MACs) will likely be using
to establish local fee schedule rates for each MoPath code (including CPT 81228–81229) in 2013:




Charges for the test and routine discounts to charges;
Resources required to perform the test;
Payment amounts determined by other payers; and
Charges, payment amounts, and resources required for other tests that may be comparable or
otherwise relevant4.
[Lab Name] believes that inaccurate rate setting for cytogenomic microarray analysis could lead to
unsustainable reimbursement rates, which would ultimately impede patient access to this medically
necessary service. Therefore, we would very much welcome the opportunity to provide [Payer Name]
with the inputs to help support accurate and sustainable reimbursement for the associated CPT codes
(81228–81229) in 2013 and beyond.
3
Manning M, Hudgins L, Professional Practice and Guidelines Committee. Array-based technology and
recommendations for utilization in medical genetics practice for detection of chromosomal abnormalities. Genet
Med 2010; 12:742.
4
Code of Federal Regulations (CFR) Title 42 - Public Health, Part 414 – Payment for Part B Medical and Other
Health Services, Section 414.508 – Payment for a new clinical diagnostic laboratory test.
In summary:



Cytogenomic microarray analysis is widely recognized as a medically useful postnatal diagnostic
tool for conditions such as developmental delay and/or intellectual disability, congenital
anomalies, and autism spectrum disorders. Effective January 1, 2013, this service will be
reported using CPT codes 81228–81229.
Accurate rate setting for CPT 81228-81229 will be critical to ensuring sustainable
reimbursement and continued patient access to cytogenomic microarray analysis when
medically necessary.
[Lab Name] seeks to better understand the rate setting process and methodologies that [Payer
Name] intends to adopt for CPT 81228–81229 (or MoPath codes in general), and would
welcome the opportunity to share the information necessary to support accurate payment
determinations.
We thank you for your time, and look forward to learning more about how [Payer Name] will be setting
payment rates for the MoPath codes, as well as any next steps that we can take to assist your
organization in the rate setting process for CPT 81228–81229 in particular.
Yours sincerely,
[Name]
[Title]
[Phone Number]
[Email Address]