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
female scientist working in a lab with a computer screen

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, two labs can bill Multi-gene Hereditary Cancer Panel tests using different CPT Code Strings (CCS):.  

Lab-A could define the cancer panel 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

Lab-B could define the cancer panel with 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, are defined by generic CPT codes that do not identify what tests were 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.  Our test mapping technology allows health plans to accurately identify tests billed with nondescript generic CPT codes. 

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!

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 290,000 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.