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Reimbursing Genetic Counselors in the Clinical Lab

by | Jan 22, 2025 | Coding-lca, Essential, Lab Industry Advisor, Reimbursement-lir

Sara Pirzadeh-Miller offers advice on overcoming the reimbursement barriers genetic counselors face in the clinical lab and beyond

Sara Pirzadeh-Miller, director of the Cancer Genetics program at the University of Texas Southwestern Medical Center, has been a genetic counselor for almost 20 years. For much of that time, like many genetic counseling clinics, Pirzadeh-Miller’s department didn’t bill for their services. That changed in late 2019, when her administration proposed implementing charges.

“At the time, I felt a lot of trepidation,” Pirzadeh-Miller says. “We have both academic and community referral bases. We weren’t sure whether providers were going to keep referring if we began billing for our services, but we needed to do it.”

The value of genetic counselors

Genetic counselors bring benefit to both patient-facing spaces and the clinical lab. “We have the ability to apply our skills across many different areas,” says Pirzadeh-Miller. “Over the last decade, we’ve increasingly become integrated into clinical labs, especially as testing has proliferated. We’re trained to help all audiences, whether that’s talking to physicians as a clinical lab genetic counselor or communicating directly with patients.”

To many people, genetics is a foreign language—one that genetic counselors can help interpret. In the clinical lab, these professionals can help communicate genetic test results to providers, guide decisions regarding further testing or treatment, and educate patients and families about the implications of their results.

“I tell my patients that anyone can have a genetic test done—but, no matter what the result is, if you don’t understand what it means for you, why did you pursue the testing?” says Pirzadeh-Miller. “I think that’s where genetic counselors shine—in making sure that information is used appropriately.”

When it comes to billing, however, that value is not reflected. “The biggest barrier we face is that we are not recognized by the Centers for Medicare & Medicaid Services (CMS) as billable providers. That’s what we’ve been working on nationally for over six years now. When we achieve Medicare recognition—and I truly believe it’s ‘when,’ not ‘if’—that will change the game. Many payers, both government and private, follow Medicare guidelines and regulations, so CMS recognition will allow us to bill for our services just like any other practitioner.”

Pirzadeh-Miller recommends that lab genetic counselors interested in getting credentialed with payers work closely with their institutions to drive that goal forward. “Our institutions’ credentialing staff have to be on board. That is a barrier for some genetic counselors I’ve spoken to around the nation. Their institutional staff don’t want to invest in the process because genetic counselors are not huge revenue producers, but it’s a necessary step before we can bill even those payers who will cover our services. Medicare may be the biggest cog in the machine, but there are many others as well.”

Becoming a recognized provider

Pirzadeh-Miller is one of the few genetic counselors who have arranged reimbursement at her institution—and she’s happy to share her experience with others.

For her department, the first step was credentialing. As soon as the paperwork was in place for private payers to recognize genetic counselors as providers, they began billing for their services. Alongside this, they instituted a monthly financial meeting to look in detail at which claims were being approved, which were being denied, and what codes were being used. “That’s how we discovered that Blue Cross of Texas was denying the genetic counselor billings,” Pirzadeh-Miller recalls. “That was a new and unexpected challenge. We had to figure out why it wasn’t connecting. It turned out that, even though we were credentialed, the payer’s system couldn’t link our provider type with the code we were using to bill for genetic counseling. They eventually recognized and documented the problem, but it took several years to fix it and to reconcile all of the patients whose claims had been wrongfully denied.”

Pirzadeh-Miller recommends that labs interested in billing for their genetic counselors’ services begin by getting to know the resources available to them at their institutions. “I didn’t know who was responsible for finances or credentials, so I went on a listening tour. I’d talk to one connection, tell them about a problem I was having, and ask them where to go next. I think that’s a huge step for anyone—finding out who at your institution needs to be in this conversation and connecting with them.” She also directs interested lab genetic counselors to the National Society of Genetic Counselors for additional billing resources and support.

Finally, patience and tenacity are essential. “None of this is going to be fast, and the more people you involve in the process, the longer it takes,” Pirzadeh-Miller says. “You have to be ready to have conversations, set up regular meetings, and stay in touch with all stakeholders. Sometimes, half the battle is just sticking with it and showing people that you aren’t going to give up.”

Billing code progress

As of January 2025, the Current Procedural Terminology (CPT) code for genetic counselors’ services has changed. The original code, 96040, stated that it was for “Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient and/or family.”1 The new code, 96041, removes the face-to-face requirement, allowing genetic counselors to bill for time spent outside patient encounters. 2 “This modernization is a huge win for genetic counselors,” says Pirzadeh-Miller. “But this is only the beginning; we’re going to keep having robust conversations about coding, billing, and how we can be reimbursed for the work we do.”

The bigger picture, she emphasizes, is the importance of genetic counseling in every aspect of healthcare, from the clinical lab to the patient encounter. “We really are a true continuum,” she says. “Our ability to be compensated and reimbursed for the services we provide affects not only us, but the entire ecosystem of clinical genetics. These conversations may not feel like they apply to everyone, but if we don’t make progress, it will affect our profession’s longevity, scalability, and the opportunities we—and the lab—will have to flourish in the long term.”

References:

    1. Parman C. Coding & Billing: Genetic Counseling. Oncology Issues. July/August 2010. https://www.accc-cancer.org/docs/documents/oncology-issues/articles/2003-2016/2010/ja10/ja10-genetic-counseling.pdf.

    1. National Society of Genetic Counselors. Change to CPT® Billing Code, effective January 2025. October 4, 2024. https://www.nsgc.org/POLICY/2025-Changes-to-CPT-Billing-Code.

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