Genetic Counseling

School of Health and Human Sciences

Rebecca FowlerBilling, Reimbursement, and Barriers of the Genetic Counseling CPT Code: The North Carolina Experience
Capstone Project Committee: Stephanie Bollinger, Sat Gupta, PhD (Statistical Consultant), Randi Stewart, MS, CGC, Carolyn Wilson-Brackett, MS, CGC
Background: In 2007, the American Medical Association introduced the 96040 CPT code to bill for “Medical Genetics and Genetic Counseling Services”.   Harrison et al. showed that a minority of counselors were billing using this code and many had encountered significant barriers in billing (2007). Purpose: The goal of this study was to investigate the billing practices of genetic service providers in North Carolina, to assess reimbursement for use of the genetic counseling CPT code, and to identify primary barriers to use of the code. Methods: Genetic service providers that are members of the North Carolina Medical Genetics Association were surveyed and one billing and reimbursement specialist was interviewed. Descriptive statistics were used to assess for trends in the data, and t-test analyses were performed to assess for associations. Results: Twenty-one respondents completed the survey. Fourteen (67%) indicated that their institution was currently billing using the code. Respondents reported significantly higher billing knowledge than reimbursement knowledge. The most commonly indicated reasons for not billing with the code included lack of state licensure, employer policies that prevent counselors from billing independently, and the perceived lack of reimbursement. The majority of respondents reported that increasing usage and consistency of the code would benefit genetic counselors (81%) and patients (76%). The interviewee suggested that a significant barrier to use of the code was poor reimbursement and advocating for better reimbursement was recommended. Conclusion: While most respondents reported billing using the genetic counseling CPT code, there are significant barriers to use of the code. Efforts to improve reimbursement and obtain licensure for genetic counselors in North Carolina may help address these barriers. Further research is needed to clarify reimbursement rates and reasons for denials, and to assess whether the code is used more often in states with licensure for genetic counselors.
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