Question 1

What is CPT-to-test mapping in a genomics laboratory?

Accepted Answer

CPT-to-test mapping is the process of connecting a laboratory's genomic test, assay components, clinical indication, and supporting documentation to the correct billing codes for claim submission. In genomics, this can involve multiple CPT codes, molecular pathology procedures, payer-specific requirements, and test identifiers such as MolDX Z-codes.

Question 2

Why are genomics claims denied so often?

Accepted Answer

Genomics claims may be denied when the submitted codes, diagnosis, documentation, prior authorization status, payer policy, test identifier, or medical necessity requirements do not align. Complex assays and changing payer rules make manual claim preparation particularly vulnerable to mapping and documentation errors.

Question 3

How can automation reduce genomics laboratory claim denials?

Accepted Answer

Automation can apply configurable rules to map each ordered test to the appropriate billing code set, required diagnosis codes, payer policies, documentation requirements, and applicable MolDX Z-codes before claim submission. It can also flag missing information and route exceptions for billing-team review before a claim is sent.

Question 4

What is a MolDX Z-code?

Accepted Answer

A MolDX Z-code is a unique identifier used by the MolDX program to identify certain molecular diagnostic tests. For applicable Medicare claims, the identifier helps connect a billed test to its technical and clinical characteristics, coverage requirements, and laboratory information.

Question 5

Can CPT-to-test mapping automation support payer-specific billing rules?

Accepted Answer

Yes. A configurable billing rules engine can apply payer-specific requirements, including coverage policies, diagnosis-code rules, authorization requirements, documentation checks, modifiers, and test identifiers. Rules should be versioned and reviewed regularly because payer policies and coding guidance can change.

Question 6

Is automated genomics billing HIPAA compliant?

Accepted Answer

Automated genomics billing systems can support HIPAA-aligned operations when they use appropriate safeguards such as encryption in transit and at rest, role-based access controls, audit logging, minimum-necessary data access, secure integrations, and documented operational policies. Compliance depends on the full technical and organizational implementation.

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