New Year, New Code: The 96041 CPT Code
By Jana Heady
The new year rings in changes, both personal and professional, for many of us, but this year carries an especially notable change for our profession: a new billing code, 96041. To help us better understand this new billing code, we reached out to Brian Reyes, MS, CGC, who wrote back addressing questions from TSGC members. If you don’t have the pleasure of knowing him already, you may recognize Brian’s name from his lecture at NSGC this past fall on this very topic. Brian is a CPT Coding Advisor to the National Society of Genetic Counselors (NSGC).
Texas Transcript (TXT): What are the differences in billing in states with and without licensure? How would getting licensure in Texas affect genetic counselors billing?
Brian Reyes (BR): Generally, billing (what codes and what forms are used) is less impacted by state licensure than credentialing. Credentialing is the process of verifying a provider has the education and certifications to practice. It ensures a provider does not have any outstanding malpractice claims against them. States with licensure are more easily able to credential genetic counselors as there is a clear state-guided process (licensure) to follow. In states without licensure, health systems and payers have to find other ways to measure these same things without state-standardized guidance. Ultimately, many health systems that provide genetic counseling services report success for billing in both states with licensure and without.
TXT: What is a simple summary of the new billing code?
BR: The new 96041 CPT code is a modernization of the existing genetic counseling CPT code, 96040, to bring us up to date with standard CPT documenting and coding in 2025. The code's most notable change is the switch from counting only face-to-face time spent with the patient to counting all time the genetic counselor spent in service to the patient on the data service.
TXT: Do you have a sense of how common or uncommon it is for genetic counselors to bill in the United States? In Texas?
BR: According to the 2023 NSGC Professional Status Survey, 63% of genetic counselors who counsel patients report that they bill for their services. Furthermore, of genetic counselors who bill, 75% do so using 96040 and will therefore now use 96041. I’m not sure of a specific number for Texas, I don’t recall if TSGC has ever surveyed its members on this topic.
TXT: How does the new billing code change what was done using the previous code?
BR: You'll notice the biggest change is how we count and document our time. Previously, with 96040 you would only count time spent directly with the patient either in person, over video, or over the phone. However, with 96041 that changes. Now we have a code that is very similar to the physician Evaluation & Management (E&M) codes. This code counts all time the genetic counselor spends in service to the patient on the date of the encounter. For example, that would include prepping your pedigree before you see the patient in the morning, the time spent seeing the patient, and time after seeing the patient spent documenting or coordinating testing. Remember, time only counts for 96041 and E&M codes if it is performed the same day the patient was seen. Hopefully this will help incentivize all of us to get our notes done!
TXT: What advice would you give to a genetic counselor that was not currently billing for their work at a health system? Where is a good first place to start?
BR: My advice is ask your administrator if billing is something that would be beneficial for your program. Would it help justify additional FTEs? Would it help you hire a GCA? Contemplate, if you switched to billing, do you have a good reason, and the leadership support, to do so?
TXT: How do we set up billing for patient results calls? Would the patient have a co-pay attached to the phone call due to billing the code?
BR: The billing is similar to typical medical billing using a telehealth modifier. However, when people ask this question I think they are often asking "What steps does my practice need to take in order to consider billing for results calls?’ One of the first questions you might want to ask is ‘Do other clinicians at our health system bill for results calls?’
If the answer is no, the next question you should ask yourself is ‘Does it make sense for us to be an exception to that rule?’ Talk with your administration and look over what it would take in order to put this into place to know whether or not it's necessary. If the answer is yes, this is normal for practices in your institution. In this case, your healthcare system already has a plan in place for how to deal with notifying patients about results calls and the necessary documentation that will be required. This is one of the areas where you will heavily want to rely on your billing and compliance teams to make sure you're following institutional protocols before starting this type of billing.
TXT: Do you have a sense of the reimbursement that has previously occurred and how the new billing code will impact reimbursement?
BR: Genetic counselors are often looking for dollar figures here. However, anti-price fixing laws prevent us from discussing financial topics. Instead, you can look at several JoGC publications by Gustafson et al. 2011, Leonhard et al. 2017, and Spinosi et al. 2021. At the 2022 NSGC Annual Conference I presented platform work from UT Southwestern titled “Approve or Deny: Experience of 96040 CPT Code Billing in a State Without GC Licensure” which showed that prior to Blue Cross Blue Shield of Texas’s (BCBS TX) recognition of GCs (which has since happened), UTSW saw 49.1% coverage. That number is now significantly higher since the change in BCBS TX policy.
The new code is anticipated to have similar value (practice expense relative value units) as 96040, but a different, more flexible, billing structure. Per unit reimbursement will roughly stay the same. How many units a practice may typically bill may differ depending on the practice’s setup.
TXT: Is there a max time limit for "prep work" or non-patient-face-time minutes that can be billed under the new code?
BR: The AMA did not set any guidelines on this code as to a maximum non-face to face amount of time that can be counted. For example, some codes use a 50% rule, meaning that at least half of the time has to be face to face with the patient. However, there is no such rule for 96041 as of yet. However, it is worth noting that any payer can audit records to make sure that the care being received is appropriate. If you anticipate documenting an unusual amount of non-face-to-face time, it may be worth making sure to document what that time entailed.
TXT: How can a genetic counselor new to billing advocate for including the new code at institutions where they are not designated as credentialed providers without a license?
BR: Practically speaking, billing at an institution where your own institution refuses to credential you is going to be an upward battle. Why would a payer credential you (and therefore contract with you) if your own institution will not? The first step is convincing your own institution that licensure is a “nice to have” not a “must have” for credentialing. Some examples of how to have this conversation:
Point out institutions that credential genetic counselors in the same state. Multiple institutions in Texas, including the University of Texas Southwestern (UTSW), have credentialed genetic counselors.
Point out that there are state-specific payers that credential genetic counselors, such as BlueCross BlueShield of Texas.
Help your team understand how they can credential you and write a genetic-counselor-specific protocol for them to use:
Teach them to navigate the ABGC website to verify your credentials
Teach them how to find your liability insurance
Learn about credentialing from the NSGC website. The Access & Service Delivery committee has put a number of resources together on this topic.
TXT: Can you provide an example of a genetic counseling clinic that has been able to successfully integrate billing in a state without licensure?
BR: In Texas, we have an excellent example of a practice billing in our state without licensure. I’m most familiar with the example of NSGC President-Elect Sara Pirzadeh-Miller, MS, CGC and the team at UT Southwestern (where I currently work). This group is successfully billing at a Texas state institution with over 20 genetic counselors. You can use them as an example to start a discussion with your team. Can you start with the small steps: institutional credentialing, getting everyone NPIs, and enrolling the GCs with payers? These are all things that can be done ahead of billing to help ease a transition.
TXT: Is the code 96041 or 90641? I heard/saw it both ways at the NSGC conference.
BR: The new code is 96041. I self-identify as ‘number-dyslexic’ and this was probably on me. Sorry!
Special thanks to Mary Grace Roden, MS, CGC, who collected the questions from TSGC membership for this article.
If your institution is currently billing and open to questions about this process, please email us at thetexastranscript@gmail.com, so we can share contact information in our Quarter 1 Recap.