Dr Wright and colleagues recently reported that from 2009 through 2013 there was underuse of BRCA testing among privately insured breast and ovarian cancer patients. As written, this analysis has several limitations that make it difficult for other clinicians and researchers to validate these findings.
Methods for identifying the patient cohort and measuring BRCA testing were not adequately described. The authors wrote that the MarketScan database was used to identify newly diagnosed patients. Unlike cancer registry data, claims data do not have a variable to identify date of diagnosis. The authors should provide readers with the combination of diagnosis and procedure codes and dates used for their inclusion/exclusion criteria.
E-mail communication with Dr Wright revealed that S-codes were used to identify patients who underwent BRCA testing. S-codes are billing codes used by private payers to identify specific health care services. During the period studied, BRCA tests were billed using methodology-based codes, S-codes, and gene-specific codes ( Table ). Therefore, Dr Wright’s analysis underestimated the rate of BRCA testing to various extent, depending upon the year analyzed. From 2009 through 2011, only S-codes and methodology codes were used. In 2011, approximately 4% of BRCA tests were billed using methodology codes. However, in 2012, BRCA tests were billed with all codes listed in the Table and S-codes represented only 32% of tests billed. Further, guidelines recommend risk assessment, genetic counseling, and then genetic testing. Some payers require a claim for genetic counseling prior to reimbursing for BRCA testing. Did the authors analyze whether patients not tested had a claim for genetic counseling? Many health care systems, including the Veterans Health Administration, recommend genetic counseling, which includes use risk assessment tools and considers the impact of test results on treatment decisions and other family members prior to testing.
| Code | Description |
|---|---|
| Methodology-based codes (until 2013) | |
| 83891 | Molecular diagnostics; isolation or extraction of highly purified nucleic acid, each nucleic acid type (ie, DNA or RNA) |
| 83898 | Molecular diagnostics; amplification, target, each nucleic acid sequence |
| 83904 | Molecular diagnostics; mutation identification by sequencing, single segment, each segment |
| 83909 | Molecular diagnostics; separation and identification by high-resolution technique (eg, capillary electrophoresis), each nucleic acid preparation |
| 83912 | Molecular diagnostics; interpretation and report |
| S codes (until 2013) | |
| S3818 | Complete gene sequence analysis; BRCA1 gene |
| S3819 | Complete gene sequence analysis; BRCA2 gene |
| S3820 | Complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancer |
| S3822 | Single mutation analysis (in individual with a known BRCA1 or BRCA2 mutation in the family) for susceptibility to breast and ovarian cancer |
| S3823 | Three-mutation BRCA1 and BRCA2 analysis for susceptibility to breast and ovarian cancer in Ashkenazi individuals |
| New gene-specific codes (introduced in 2012, currently in use) | |
| 81211 | BRCA1 , BRCA2 gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835 kb, exon 13 dup 6 kb, exon 14-20 del 26 kb, exon 22 del 510 bp, exon 8-9 del 7.1 kb) |
| 81212 | BRCA1 , BRCA2 gene analysis; 185delAG, 5385insC, 6174delT variants |
| 81213 | BRCA1 , BRCA2 gene analysis; uncommon duplication/deletion variants |
| 81214 | BRCA1 gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835 kb, exon 13 dup 6 kb, exon 14-20 del 26 kb, exon 22 del 510 bp, exon 8-9 del 7.1 kb) |
| 81215 | BRCA1 gene analysis; known familial variant |
| 81216 | BRCA2 gene analysis; full sequence analysis |
| 81217 | BRCA2 gene analysis; known familial variant |
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