Test Mapping

Test Identification and Mapping

Test identification and mapping mean high-quality claim editing.   With over 20K tests in the market today, many defined with unique CPT code combinations, it’s important to be able to accurately identify billed tests at the point-of-claim-adjudication in order to accurately:

  • Apply claim and pricing edits
  • Identify billed tests subject to prior authorization and advance notification
  • Identify unproven tests ineligible for payment

The Need for Test Identification and Mapping

There are three key lab coding identification issues in the absence of industry coding standards.  Yes, CPT codes are standard, but labs define tests with non-industry standard proprietary test codes that are associated with one or more CPT codes.

Issue #1:  Different tests can be defined with the same CPT code.  For example, Lab-A could bill a Congenital Muscular Dystrophy test and Epilepsy test with CPT code 81433.  How would you edit and apply policies to the 81433 CPT code, without knowing what test is being billed? 

We have solutions!

Issue #2:  Similar tests can be defined with different CPT codes.  For example, Lab-A could bill billed two different Multi-gene Hereditary Cancer Panel tests.  

Test-1 could be defined with the following CPT-code string: 81162×1, 81201×1, 81203×1, 81292×1, 81294×1, 81295×1, 81297×1, 81298×1, 81300×1, 81317×1, 81319×1, 81321×1, 81323×1, 81403×1, 81404×002, 81405×002, 81406×002, 81408×1, 81479×1

Test-2 could be defined with the a somewhat different string of CPT codes:  81162×1, 81321×1, 81323×1, 81404×1, 81405×002, 81406×002, 81408×002, 81479×1.

We have solutions!

Issue #3:  Some tests, including unproven tests that are ineligible labs, are defined by generic codes that do not identify what tests was performed.  For example, we have observed that a single 81479 CPT code can be used to bill any number of tests, including these “unproven” tests: Liquid Biopsy, Multi-Gene Pharmacogenetic Testing, and Gene Expression for Prostate Cancer.  Test identification methods to accurately adjudicate test claims, and especially to distinguish proven from unproven tests.  

We have solutions!

These scenarios demonstrate the challenge of accurately identifying billed tests and therefore accurately applying claim edits and policies.  And, these issues are compounded when generic codes can be used with many different tests as highlighted in examples #2 and #3.

We have solutions!

Sometimes the tests meet a health plan’s policy guidelines, but in some cases, they fall outside the regulations or are unproven. When testing does not follow policy guidelines, a health plan may deny coverage. That’s why test mapping solutions are essential to ensuring patients get the care and coverage they need.

Our Test Identification and Mapping Solutions

We have solved the test identification challenge with our proprietary test mapping technology and processes.

Our test mapping technology is comprehensive and wide-reaching. We have mapped over 90% of the laboratory tests performed in the U.S., with more than 250,000 tests in our test mapping database.

Contact Us for Exceptional Data Solutions

Health plans rely on our test identification and mapping systems for accurate test identification and claim adjudication. To learn more about how our system works, contact us today to schedule a demo.