In 2021 I was hired at Massachusetts General Hospital as the first genetic counselor in the pathology department. The vision of the in-house laboratory responsible for tumor testing was to create a molecular consultation service that would support oncologists with complex cases. Those of you who work in oncology may have seen some of the recurrent questions that arise in this specialty, particularly around somatic test results: for example, “Does my patient need germline testing?”, “Is this tumor a metastasis or new primary?”, “Is this mutation targetable?” and, inevitably, “Can we do something about this $5,000 bill?” The lab needed someone who could act as a liaison among clinicians, pathologists, patients, lab techs, other labs, finance and anyone else who might be involved. They needed this someone to have communication skills and subject matter expertise. They thought a genetic counselor was perfect for the job.
I agree: As biomarkers for therapeutic, diagnostic and prognostic purposes continue to be identified and targeted, genetic counselors have a clear opportunity to support our networks — colleagues, patients and the general public — through the implications of this genetic data.
Thus, I was tasked with helping to build and run this service. The goal was not only to create a systematic way to answer, document, and track these exchanges, but also to ensure that work was reimbursed. It took several months, but we eventually created a successful workflow.
With four clicks, a clinician could submit a question that would act as a documented order (for compliance purposes) that the core consultation team, made up of myself, a medical technologist and the molecular pathologist on service, would then address in a detailed, billable report uploaded to the patient’s electronic medical record. We were reimbursed by a wide range of payers. We identified different trends, defined categories for the types of questions we received and tracked outcomes.
More often than not, our consultations offered a management change. We might reveal that the patient had an indication for a targeted therapy, or we might provide evidence for a particular diagnosis, or recommend and assist with a referral to genetic counseling. Our reports lived in the patients’ charts, where they could be accessed by current and future clinicians who could review our concise summary rather than 10 years of disparate progress notes and lab results filed away in different locations by inconvenient EMR logic we also advocated to update.
Unlike external labs, we had access to the patients’ entire charts and often had their tissue on hand, so we were able to carry out further investigations more quickly and efficiently than an outside party. The report we issued contained the clinician’s question, our concise answer, and then several pages of background and justification: medical and family history, an emphasis on treatments, pathology reports, genetic testing both internal and external, charts and tables we created to compare results, a discussion of any relevant literature, descriptions of any communications with outside institutions such as a phone call with an outside lab to get technical information about their assays that might reveal why we saw discrepant results, and so on.
This was exciting! These were important questions! They had important answers! I gave poster presentations1,2,3 around the country, I gave talks to colleagues and classrooms and conference attendees4, we were featured in newsletters through the hospital network and through the College of American Pathologists5. Folks I met at conferences told me how much their own institutions could benefit from a service like this and asked me how they could design their own. It was clear that the molecular consultation service plugged a gap created by the rapid advancement of precision medicine and the increasing demands on providers related to this field.
The catch, though, is that the CPT codes in question (clinical pathology consultation codes) are time-based and only billable for MDs. My time, which might be hours of pouring over the patient’s entire available medical history, digging through the literature and drafting up a report summarizing our findings and conclusions, was invisible. MD time, though sometimes lengthy, was more often a few minutes of glancing over the report and adding a time stamp and a signature. Something that took, say, three hours, would be billed at 10 minutes.
Ultimately, as a GC-reliant project, this service was not profitable. The endeavor as I’ve described it lasted approximately two-and-a-half years, barely out of the pilot period. I have since moved on to an industry role, and the lab I left has shifted and changed. I still believe in a centralized service dedicated to addressing complicated cases that involve molecular testing, and I still believe genetic counselors are uniquely positioned to champion this emerging specialty. However, I now know it will require updated billing practices, consistent and authentic buy-in from leadership, and the kind of institutional flexibility that innovation requires. I remain happy to discuss the service and my experience with it in more detail, and I hope to see my colleagues inventing their own versions as new breakthroughs in precision medicine continue to emerge.
- Finer, A., Pannone, A., Bard, A., Green, U., Ritterhouse, L., Dias-Santagata, D., Lennerz, J. (2022, July 31-August 3). Clinical Implementation of a Precision Medicine Consultation Service [Conference poster presentation]. Cancer Genetics Consortium 2022, St. Louis, MO, United States.
- Finer, A., Pannone, A., Bard, A., Green, U., Ritterhouse, L., Dias-Santagata, D., Lennerz, J. (2022, November 1-5). Clinical Implementation of a Precision Medicine Consultation Service [Conference poster presentation]. Association for Molecular Pathology Annual Meeting & Expo 2022, Phoenix, AZ, United States.
- Finer, A., Pannone, A., Bard, A., Green, U., Ritterhouse, L., Dias-Santagata, D., Lennerz, J. (2023, May 5-7). Clinical Implementation of a Precision Medicine Consultation Service [Conference poster presentation]. City of Hope’s From Precision Medicine to Precision Prevention: Joining Forces Across the Spectrum of Care, Los Angeles, CA, United States.
- Finer, A. (2024, April 26). Somatic Testing and the Genetic Counselor’s Role in Precision Oncology [Conference talk]. Dana-Farber Cancer Institute’s Cancer Genetics: Uncharted Territory, Boston, MA, United States.
- CAP Today. (2023, September 19). Genetic counseling within the laboratory: For oncology cases, lab’s consult service plugs gap - CAP TODAY. https://www.captodayonline.com/genetic-counseling-within-the-laboratory-for-oncology-cases-labs-consult-service-plugs-gap/
Abby Finer is a variant scientist and genetic counselor. She is part of the clinical science team at Tempus AI where she classifies somatic and germline variants for liquid biopsy, panel tests and WES. She received her genetic counseling master’s degree as part of the inaugural class at the MGH Institute of Health Professions, and her bachelor’s degree in philosophy from Bard College. She previously held a position at Massachusetts General Hospital as the first genetic counselor in the pathology department, working with somatic and germline testing to address complex cases in oncology.