As advancements in molecular diagnostics continue to evolve, next-generation sequencing (NGS) testing represents an exciting opportunity for physician-owned laboratories to expand their services. Beyond providing cutting-edge insights into oncology and OB-GYN care, adding NGS testing can position your laboratory as a leader in precision medicine.
But how should labs and physicians approach navigating the complexities of implementation, documentation, and reimbursement to ensure a smooth transition? In the guide below, we outline a strategic pathway to integrating NGS testing into your laboratory’s offerings, along with steps and considerations to overcome common challenges.
Why Expand into NGS Testing?
NGS testing is transforming care in specialties like oncology and OB-GYN by enabling the detection of genetic markers that guide targeted treatments. With the right setup, your lab can meet growing provider demand for advanced molecular testing and unlock new revenue streams.
For instance, CPT codes such as 81445, 81449, 81450, and 81451 are commonly used for NGS services within these specialties. While these codes open doors to new opportunities, they also come with billing and coding intricacies that require careful attention.
Key Considerations for Successful Implementation
- Accurate Coding and Clean Claims Submission
Billing for NGS testing demands precision. Each test must align with a single CPT code, avoiding code stacking. To meet most payer requirements, include:
- The specific gene being tested.
- A detailed description of the test (up to 80 characters) in the narrative section of your CMS-1500 claim form (Box 19).
- Relevant medical records that support medical necessity.
- Robust Documentation and Training
As always, documentation is the backbone of clean claims and successful reimbursements. However, ensuring this is done correctly requires:
- Training providers to document medical necessity accurately (e.g., specific ICD-10 codes vary by payer).
- Aligning lab processes with local and national coverage determinations (e.g., Novitas LCD Reference Article A58917).
- Navigating Payer Requirements and Challenges
Many payers, including UnitedHealthcare and Cigna, have adopted policies like MolDX, which require additional documentation and Z-Codes for certain tests. Labs must stay informed about these evolving requirements and implement robust feedback loops to address rejections and manage appeals efficiently.
Overcoming Common Pitfalls
Adding NGS testing involves more than technical upgrades; it requires strategic cost management, ongoing training, and readiness for administrative hurdles. Some items to consider include:
- Lifetime Testing Limits: Many genetic codes are reimbursable only once per lifetime.
- Reimbursement Denials: Policies like Z-Code requirements often act as barriers rather than paths to payment.
- Increased Administrative Load: Payer policies and benefit management programs like those from EviCore, Optum, and Avalon demand rigorous adherence to technical and clinical validity standards.
The Lighthouse Lab Services Advantage
Lighthouse Lab Services RCM experts understand the complexities of expanding laboratory services, particularly with advanced molecular testing. Whether you need guidance on coding, documentation, or compliance with the latest reimbursement policies, our team is here to help.
Expanding into NGS testing can set your laboratory apart in the eyes of payers while providing invaluable insights for patient care. Ready to explore this opportunity? Connect with Lighthouse Lab Services today to schedule a complimentary consultation and take the first step toward transforming your lab’s capabilities.