The CPT Workgroup within the National Society of Genetic Counselors (NSGC) Access and Service Delivery Committee had the opportunity to sit down with a CPT expert and ask questions about the recently added -93 modifier for CPT code 96040. In this article, we describe the existing 96040 CPT code, the new -93 modifier, and provide action steps you can take in your current professional role. Understanding the landscape of how genetic counseling services are billed may allow you to better address current and future challenges with reimbursement, strengthen your case when advocating for new genetic counseling positions, and promote job security for existing positions.
History of CPT Code 96040 and Telehealth Codes
In 2005, NSGC proposed a genetic counseling CPT code (96040) to allow reporting for 30-minute face-to-face genetic counseling performed by a genetic counselor. The 96040 stackable code allows for each 30-minute unit charge to be billed once a 16-minute interval has been reached.
The term “face-to-face” was included in the description because the genesis of the code was for in-person counseling; however, it remained ambiguous if video consultation was permitted under the code. As technology created opportunities for telehealth, various professional organizations, including the NSGC, recognized the need for a CPT code modifier to designate video consultations. Thus, in 2017, the American Medical Association (AMA) added the video-only -95 modifier, which can be used with 96040. There still remained a need to distinguish between video-only and audio-only genetic counseling. This need led to the creation of the -93 modifier which was newly issued in January 2023, allowing for reimbursement of audio-only genetic counseling services. All telehealth modifiers for 96040 (both -95 and -93) were approved because we were able to show non-inferiority of telehealth consults compared to in-person consults which is required by the AMA.
Newly Issued Audio-only -93 Modifier for 96040
We had the opportunity to sit down with Brian Reys, MS, CGC, the AMA CPT Editorial Panel Health Care Professionals Advisory Committee (HCPAC) Advisor to NSGC for an informational interview regarding the new -93 modifier.
Q1: What is the Audio-only -93 Modifier and when can it be used?
A1: Effective January 1, 2023, the -93 modifier code can be used with 96040 when a patient is counseled via audio-only. For example, if counseling a patient via telephone for 16 minutes, a genetic counselor (GC) can bill with CPT code 96040-93. Typical billing requirements for 96040 are needed, this is solely a modifier to designate the conversation via audio.
Q2: What are the time requirements for 96040 modifiers (-95 and -93)?
A2: 96040 designates time spent counseling. The modifier indicates the method of counseling delivery (-93 for audio only, -95 for video). One unit of 96040 equates to 30 minutes of direct patient counseling time. A minimum of 16 minutes is required to bill one unit. For example, if you see a patient for 46 minutes via telephone, a GC would bill 2 units of 96040 and include one -93 audio-only modifier. Modifiers are added once to the base 96040 code.
Q3: How does a genetic counselor billing for audio only (96040 with -93 modifier) services differ from how a physician or other providers bill for audio only services?
A3: Physicians and other providers use Evaluation and Management (E&M) codes (not 96040). Some CPT codes are valued to include items like desk chairs, space, and physical exam; therefore, not all codes are approved for use with the telehealth modifiers; the valuation of the service changes when done remotely or via audio only. Physicians and other providers use separate codes for audio and video visits that accommodate the different service components.
Q4: Are we seeing the same level of reimbursement for 96040 used on its own for in-person genetic counseling compared with 96040 with the -93 modifier for an audio-only genetic counseling visit?
A4: There is no published data yet, however, data presented at the 2022 NSGC conference showed similar levels of reimbursement of 96040 alone compared to 96040 with the -95 video modifier.
Q5: How should a genetic counselor document a service if they start the visit with video but due to technical difficulties need to switch to audio-only?
A5: Genetic counselors are recommended to ask the specific payer or institution as payers may have their own unique rules for this situation.
Q6: How are health insurers alerted to the new modifier? A6: The AMA updates the AMA CPT Professional Edition coding book annually. A CPT Assistant article is also distributed that highlights any coding changes.
Q7: If an insurer is denying claims submitted with the modifier code, what data can we provide?
A7: Direct them to the most recent AMA CPT Professional Edition, which is published yearly. Appendix P lists the -95 modifier and Appendix T lists the -93 modifier.
Q8: Who should genetic counselors notify at their institution about this new -93 modifier audio only code?
A8: Genetic counselors billing with 96040 should make sure their leadership, medical coders, billing staff or whomever covers reimbursement for their services are aware of this new -93 modifier code.
What you can do to help
Below are some action steps that genetic counselors can take in response to the 96040 CPT code updates.
- Stay abreast of NSGC’s efforts regarding updating 96040.
- Proactively discuss billing practices of 96040 and the telehealth modifiers with your institution’s billing team to ensure appropriate use.
- Review and stay up to date on national and state coverage changes and requirements surrounding CPT codes. For example, the public health emergency ended May 11, 2023, which may have an impact on certain codes.
- Ask for your billing data and reimbursement information from your institution, so you can track/measure your value. This information will help GCs in general, as billing and reimbursement data is not something that is generally reported to NSGC’s Professional Status Survey (PSS).
- Review your own state-specific rules related to CPT issues (example: in Texas “N modifiers” are used in place of “GT” modifiers). Your institution’s billing professionals should be aware and in compliance with any state specific billing rules.
- Use available resources that may be helpful in discussions with your institutions’ billing department.
- For example, the CPT 2023 book (your billing department should have access to this resource). You can access other resources related to the CPT codes at the NSGC Coding Resources.
- If you have any questions related to CPT coding and billing for genetic counseling services, please contact the NSGC Access and Service Delivery’s Committee Liaison, Jennifer Trotter at email@example.com.