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Support services insights: How should you provide and bill for genetic counseling?

July 15, 2016

    This is part of a weekly series on results from our 2015 national benchmarking survey on cancer program support services volumes, staffing, and operations.

    As many as half of all genetic tests ordered today are inappropriate, either because the patient is not high-risk or providers ordered the wrong type of test. To improve that number, patients need access to genetic counselors.

    Cancer program leaders have approached genetic counseling services in innovative ways given the staff shortage and limited reimbursement, but what approach is best for your organization? To help you find out, we surveyed more than 150 cancer programs about their genetic counseling services.

    AMCs and teaching hospitals more likely to have dedicated genetic counseling staff

    Driven by advances in genetic testing and accreditation requirements, most cancer programs (64%) employ dedicated staff to provide genetic counseling services. Not surprisingly, AMCs (88%) and teaching hospitals (70%) are the most likely to hire dedicated genetic counseling staff. AMCs also tended to hire more staff, with a median of 2.0 FTEs. Overall, survey respondents provide genetic counseling to a median of 120 patients a year.


    Most cancer programs hire licensed genetic counselors

    Although staff with a variety of backgrounds can provide genetic counseling services, most cancer programs hire licensed genetic counselors (88%). However, a shortage of certified genetic counselors, as well as reimbursement challenges, means that many cancer programs have to look to other options. Almost 20% of survey respondents indicated that they use genetics clinical nurses (19%) and advanced practice nurses (18%) either in lieu of or in conjunction with licensed genetic counselors.

    Notably, the Genetics Nursing Credentialing Commission (GNCC), which issued the genetics clinical nurse (GCN) credential, is now defunct so we can expect this role to become less common in the future. However, advanced practice nurses can still receive their Advanced Genetics Nursing-Board Certified (AGN-BC) credential through the American Nurses Credential Center (ANCC), which has taken over this certification for the GNCC.


    Billing for genetic counseling services vary widely

    Despite the benefits of genetic counseling, reimbursement remains limited. This is primarily because licensed genetic counselors are not recognized as independent non-physician providers by Medicare and can only bill directly for their services using CPT code 96040.

    Unfortunately, reimbursement for this code is low. Under the 2016 Outpatient Prospective Payment System (OPPS) and the Physician Fee Schedule (PFS), it is not a separately reimbursable service. Private payers vary in their coverage. According to one study by the Cleveland Clinic, only 62% of encounters billed to private payers using code 96040 received some reimbursement.

    Due to these reimbursement limitations, cancer programs often adopt a variety of billing approaches to enhance payment, including billing directly for physician time or incident-to services. According to our survey, the most common aspects that cancer programs bill for are genetic counseling staff time (42%) and facility fees (32%). Fewer bill for physician time—only 24%.


    Limited reimbursement and the cost of employing licensed genetic counselors in the midst of a workforce shortage have compelled some cancer programs to look at alternatives, such as exploring ways to leverage telehealth or outsourcing to a third party. To find out more, read our blog post on how The Comprehensive Breast Care Center of Tampa Bay outsourced their genetic counseling to InformedDNA.

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