2025 CPT code 96040
(Active) Effective Date: N/A Revision Date: N/A Medicine - Medical Genetics and Genetic Counseling Services Medicine Feed
This code represents medical genetics and genetic counseling services provided face-to-face with the patient/family, for each 30 minutes.
Modifiers may be applicable to this code, including -93, for audio-only services provided via telephone or other real-time interactive audio-only telecommunications systems, and -95, synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.
Medical necessity for genetic counseling is determined by the patient's individual circumstances and risk factors, which may include personal or family history of genetic disorders, abnormal test results, or specific medical conditions.Refer to payer-specific guidelines for coverage details.
A trained, non-physician genetic counselor performs this service, which includes collecting family history, reviewing medical records, creating a pedigree, assessing genetic risks, creating a formal report with analysis and recommendations, and providing counseling to the patient and family. Physicians should use E/M codes when providing genetic counselling services.
In simple words: A genetic counselor helps patients and families understand inherited health risks by analyzing family history, medical records, and genetic test results. They provide support and guidance, explaining complex information in a clear way.
This service involves a trained genetic counselor providing genetic counseling and education which may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family. These activities may be provided during one or more sessions and may include review of medical data and family information, face-to-face interviews, and counseling services.One unit of 96040 equates to 30 minutes of direct patient counseling time, and a minimum of 16 minutes is required to bill one unit. The -93 modifier can be used with 96040 for audio-only counseling effective January 1, 2023. The -95 modifier is used to report telehealth services provided via real-time interactive audio and video telecommunications systems.
Example 1: A 30-year-old woman with a family history of breast cancer seeks genetic counseling to understand her risk and testing options., A couple expecting a child undergoes genetic counseling after a positive prenatal screening test., A patient with a newly diagnosed genetic condition receives counseling to understand the implications for themselves and their family.
Documentation should include details of the family history, pedigree, risk assessment, counseling provided, and any recommendations made. Time spent face-to-face with the patient/family must be documented to support the number of units billed. For audio only telehealth services the -93 modifier should be appended to 96040. For video and audio telehealth services -95 should be used.
** Reimbursement for this code varies among payers. Medicare does not typically provide separate payment for 96040, but other payers may reimburse under specific circumstances. Always verify coverage with the individual payer before providing services. HCPCS code S0265 may be used by some payers. It is important to note that the place of service is highly dependent upon payer requirements. Some payers have special requirements for telehealth services.
- Revenue Code: T2D - OTHER TESTS - OTHER
- Payment Status: Dependent on Payer and Provider
- Specialties:Genetics, Oncology, Obstetrics/Gynecology, Pediatrics and other medical specialties who provide genetic counseling services.
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, telehealth applicable.Place of Service varies according to payer guidelines.