Proactively manage genetic test spend
As genetic testing becomes the standard of care for many health conditions, the number of tests available in the market has soared. With over 10 new tests added daily, many don’t meet the criteria for clinical or analytical utility. And with fewer than 500 CPT® billing codes to describe the nearly 130,000 genetic tests available in the market, reimbursement can be complex. 1,2
Optum® Genomics Payment Manager helps health plans proactively manage genetic testing spend by correctly identifying tests, automatically mapping billing codes to genetic tests and analyzing claims for inappropriate billing behaviors.
Unique test identification
Through our exclusive partnership with Palmetto GBA, who administers the MolDX program leveraged by Medicare Fee-For-Service (FFS), we utilize the reliable DEX® Diagnostics Exchange. This platform assigns unique DEX Z-Code® identifiers to each test, aiding in the cataloging and management of the tests. By leveraging these familiar processes, we help validate that only clinically relevant and appropriate tests are covered, aligning with health plan policies.
Z-Codes drill down beyond the CPT® code and identify a discrete genetic test on a claim, allowing for automated correct coding edits, Medicare-sourced coverage determinations and pricing recommendations.
Improve regulatory compliance
DEX Z-Codes® are an extension of the Medicare FFS MOlDx program, which has been used for over a decade by Medicare Administrative Contractors (MACs) to improve payment accuracy on genetic testing claims.
Biomarker compliance laws vary by state. Some states require health plans to cover biomarker testing similar to Medicare Fee-For-Service (FFS). Genomics Payment Manager can help health plans improve patient access to necessary tests.
Key benefits
Support biomarker compliance and accurate reimbursement for genetic testing.
Greater policy enforcement and payment specificity
We create a one-to-one relationship between the Z-code, CPT code, test and lab, allowing for automated policy enforcement and payment decisions at the discrete test level.
Commitment to test quality
The DEX® Diagnostics Exchange performs clinically stringent technical assessments on all lab-submitted tests to help validate quality for members and physicians.
Genomics Payment Manager FAQ
Genetic tests are primarily identified in claims using CPT, PLA or HCPCS codes. However, many genetic tests share the same codes, particularly unlisted or panel-based codes, which do not provide sufficient detail about the specific test performed. To address this lack of precision, additional identifiers such as DEX Z-Codes® may be required to uniquely identify the exact test.
A DEX Z-Code® is a unique identifier assigned to a specific genetic test by Palmetto GBA® through the DEX® Diagnostics Exchange. It links a claim to detailed information about the test, including the performing laboratory, methodology and clinical purpose, enabling precise identification beyond what standard procedure codes can provide.
While DEX Z-Codes® originated within the Medicare MolDX® Program, their use has expanded to commercial health plans and managed Medicaid. Many payers are beginning to require Z-Codes® to improve transparency in genetic testing; however, realizing their full value for utilization and reimbursement management requires an integrated solution such as Genomics Payment Manager.
Genomics Payment Manager helps control spend by introducing test-level visibility and enforcement by:
- Identifying the exact genetic test billed using the Centers for Medicare & Medicaid Services (CMS)-endorsed DEX Z-Codes®
- Applying coverage and reimbursement policies at the test level rather than CPT®/PLA/HCPCS code level
- Preventing payment for non-covered, duplicative or low-value tests
- Enabling consistent application of policy across lines of business
- Reducing manual review with automated policy enforcement at the claim line
This level of precision can significantly reduce inappropriate utilization and improves cost containment.
Genomics Payment Manager supports compliance by aligning claim adjudication with established policies and regulatory requirements, including:
- Consistently enforcing CMS and other payer-specific policies
- Providing auditability and traceability for decisions tied to specific tests
- Supporting adherence to CMS and biomarker expectations, where applicable
- Helping reduce variability and risk associated with manual or inconsistent review processes
This creates a more defensible, transparent framework for managing genetic testing in line with evolving regulatory standards.
Industry insights
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On-demand webinar
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On-demand webinar
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Complementary solutions
Software
DME Navigator
Our integrated durable medical equipment (DME) solution helps health plans manage spend while improving the experience for members, DME suppliers and the ordering providers
Solution suite
Ancillary Benefits Management
Reduce the burden of managing ancillary benefits programs separately across the care continuum. Our solutions leverage an affordability framework to close gaps for better care with lower costs.
Sources
- Halbisen AL, Lu CY. Trends in Availability of Genetic Tests in the United States, 2012-2022. J Pers Med. 2023 Apr 6;13(4):638. doi: 10.3390/jpm13040638. PMID: 37109024; PMCID: PMC10142561.
- Laboratory Hub. Laboratory Hub. Understanding CPT and ICD Codes in Laboratory Billing. Oct. 7, 2023.