American Genetic Counsellors Secure New Billing Code: A Milestone in Professional Recognition

The field of genetic counselling has seen significant growth in recent years, with genetic counsellors playing an increasingly critical role in the healthcare landscape. Their expertise in genetic testing, risk assessment, and patient education is indispensable in navigating the complexities of genetic diseases. However, as genetic counsellors have grown more integral to patient care, challenges around billing and reimbursement have become more pronounced. In a significant achievement, genetic counsellors in the United States have secured a new billing code—CPT 96041—that promises to better capture the work they do. Current Procedural Terminology (CPT) billing codes are a standardized system used by healthcare providers in the U.S. to document and bill for medical services and procedures. Developed by the American Medical Association, these codes ensure that healthcare providers can accurately bill insurance companies and other payors for the specific services they offer, enabling consistent reimbursement practices across the healthcare industry. This development, announced in September 2024, is a pivotal step forward in recognizing the value of genetic counsellors and securing appropriate compensation for their time.

A Move Away from Face-to-Face Requirements

Historically, the Current Procedural Terminology (CPT) code 96040, implemented in 2007, allowed non-physician genetic counselors to bill for their services. However, this code had significant limitations. It required genetic counselors to spend between 16 and 30 minutes in face-to-face consultations with patients, a requirement that did not reflect the full scope of their work. Genetic counsellors often spend considerable time before and after consultations reviewing patient files, preparing for appointments, ordering tests, coordinating care with other healthcare professionals, and writing detailed reports. Unfortunately, the time spent on these critical tasks was not eligible for billing under CPT 96040.

The introduction of the new billing code, CPT 96041, eliminates the face-to-face requirement, marking a key shift in how genetic counselling services can be billed. Under the new code, genetic counsellors can now bill for any medical genetics and counselling services, including preparatory and post-appointment work, as long as it is performed on the same day as the patient encounter. This new flexibility is expected to better capture the actual time spent on patient care and increase the number of billable units for genetic counsellors.

Implications for Genetic Counseling Practice

While the new billing code is a significant advancement, it comes with certain stipulations. The work eligible for billing must still be completed on the same day as the patient visit. This means that if a genetic counsellor reviews a patient’s case three days in advance or completes documentation the day after, that time cannot be billed. This requirement may necessitate changes in workflow for some genetic counsellors. For example, clinics that currently alternate patient days between genetic counsellors may need to adjust their scheduling to allow for same-day documentation and chart preparation.

Despite these logistical challenges, the overall impact of the new CPT code is expected to be highly beneficial. According to an analysis by the National Society of Genetic Counselors (NSGC), the majority of genetic counselors will be able to bill for more time under the new code. On average, counsellors who previously billed for one unit of time under CPT 96040 will now be able to bill for two units under CPT 96041. This change is projected to benefit over 93 percent of genetic counsellors, allowing them to bill an additional 1.54 time units per consultation.

Payor Considerations and Future Challenges

While the introduction of CPT 96041 is a major milestone, some challenges remain. One significant concern is how payors—such as insurance companies and government programs—will respond to the new code. In the U.S., payor coverage for genetic counselling services has been inconsistent, and some genetic counsellors are concerned that insurance companies may not reimburse for the expanded services captured under CPT 96041. The NSGC has been proactive in addressing this issue, sending letters to major national payors to notify them of the change and to advocate for continued coverage of genetic counselling services under the new code.

In addition to private payors, genetic counsellors in the U.S. are still fighting for recognition by the Centers for Medicare and Medicaid Services (CMS). Although CPT 96041 will appear on the CMS Physician Fee Schedule, it is currently classified as a status B code, meaning CMS is not planning to recognize it for reimbursement. This lack of recognition from CMS remains a significant hurdle in securing widespread coverage and reimbursement for genetic counselling services, particularly for elderly and low-income patients who rely on Medicare and Medicaid.

A Step Forward, But More Work to Be Done

While there is still progress to be made, the introduction of CPT 96041 is a major achievement for the genetic counselling profession in the United States. It reflects growing recognition of the vital role that genetic counsellors play in patient care and lays the groundwork for improved reimbursement. This change not only benefits genetic counsellors but also enhances the accessibility of genetic counselling services for patients, ensuring they receive the comprehensive care they need in an era of increasingly personalised medicine.

The journey toward full professional recognition and equitable reimbursement continues, but this new billing code is an important step toward that goal. For genetic counsellors in Australia, the situation is somewhat different. After failing to gain registration through the federal government, the profession has moved towards self-regulation through the National Alliance of Self-Regulating Health Professions (NASRHP). Additionally, the profession continues its efforts to obtain a Medicare item number, which would allow Australian genetic counsellors to bill for their services, similar to their U.S. counterparts. Despite these challenges, the demand for genetic counselling services in Australia continues to grow, with increasing recognition of the critical role genetic counsellors play in personalised healthcare.