Provider Alert! Gene Expression Profiling Procedure Code 81520 to Become a Benefit Effective April 1, 2022

Date: February 9, 2022

Attention: Providers

Subject:

Effective Date: April 1, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: On September 11, 2020, Texas HHSC received a medical benefit request to add Prosigna®, a type of gene expression profiling, as a benefit of Texas Medicaid. Prosigna® is a diagnostic laboratory test that is used to determine the risk of recurrence in early-stage breast cancer. Effective for dates of service on or after April 1, 2022, gene expression profiling procedure code 81520 will become a benefit of Texas Medicaid. Procedure code 81520 will be a benefit when all the following criteria are met:

• The clinical stage of the breast cancer is I or II, and the cancer has not spread to more than three lymph nodes.
• The primary tumor is hormone receptor positive.
• The client is female and post-menopausal.

How this impacts providers: Procedure code 81520 may be reimbursed for female clients of all ages who meet the above criteria, to physician providers for services rendered in the office setting, to hospital providers in the outpatient hospital setting, and to independent laboratory providers in the laboratory setting.

Procedure code 81520 may be reimbursed once per lifetime, any procedure, any provider, when submitted with one of the following diagnosis codes:

Procedure codes 81519 and 81520 may be reimbursed more than once per lifetime for the same client on appeal, if the provider submits documentation demonstrating that the client has a new, second primary breast cancer diagnosis.

Updated Criteria for Procedure Code 81519

Procedure code 81519 is a benefit when all the following criteria are met:

• The clinical stage of the breast cancer is I, II, or IIIa, and the cancer has not spread to more than three lymph nodes.
• The primary tumor is estrogen receptor positive and Her-2/neu receptor negative, or the primary tumor is Her-2/neu receptor positive and less than 1 cm in diameter.
• The client is a candidate for adjuvant chemotherapy.
• The outcome of the test will guide decision-making regarding adjuvant chemotherapy.

Next steps for providers: Prescribers should share this communication with their staff

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.