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Frequently Asked Questions:  CMS Recognition of Genetic Counselors

Soon, Representative Erik Paulsen (R-MN) should be introducing legislation that would allow CMS (Centers for Medicare and Medicaid Services) to recognize genetic counselors as providers. This recognition will improve access to genetic counselors for Medicare beneficiaries and allow reimbursement by CMS for the service.

The following are some frequently asked questions we have received from NSGC members:

Why is this taking so long?

Rather than introduce a bill and then work to build support, NSGC has worked closely with the House Ways and Means Committee to develop a bill with committee input. Because of the preparation done on the front end, both Democrats and Republicans should support the legislation broadly. This process certainly has taken time but should pay off once the legislation is introduced. 

With Committee buy-in, the bill has a greater possibility to move through the legislative process. The House Legislative Counsel, which drafts official bill language, is currently adding the last Committee recommendations to the bill. The bill will move to introduction shortly after we receive it back from Legislative Counsel. 

How does the bill improve access to genetic counselors?

After the legislation is enacted, genetic counselors will be able to see patients independent of any supervision and directly receive referrals. Essentially, it will mirror how services should be provided in states with licensure.

Today, even when genetic counselors hold a license that allows them to practice independently, they must see a Medicare beneficiary under the supervision of a physician and follow other “incident to” rules. These rules also require a Medicare beneficiary to be an established patient. Therefore, patients from practices or hospitals that do not have a genetic counselor would likely not be seen by one as these groups would be required to refer to another physician that works with a genetic counselor first to establish the patient... Then the patient would need to return on a different day to see the genetic counselor. The inefficiency of this process combined with the chance of losing a patient to the new physician creates enormous barriers to these referrals, particularly when the referring physician can provide the service himself or herself, even if quality suffers.

How might referrals change?

With the enactment of this bill, genetic counselors could see Medicare beneficiaries without supervision. This will create consistency between state licensure and CMS policy. Physicians that may be hesitant or might not be able to refer to genetic counselors today, due to “incident to” rules, could directly refer to the genetic counselor, and the genetic counselor could refer the patient right back to the referring physician after post-test counseling.

How does the legislation define a genetic counselor?

Genetic counselors will be able to enroll as Medicare practitioners if they are licensed in their state or are certified by the American Board of Genetic Counseling (ABGC), where licensure is not available.

Does the bill align with state licensure laws?

The bill is very similar to a state licensure bill but is not “national licensure.” Those who practice in states with licensure would follow their state’s scope of practice when delivering services. For these genetic counselors, service delivery should become consistent over all payers.

If the bill is enacted, genetic counselors practicing in states without licensure will follow the scope of practice defined in the federal legislation, but only for Medicare beneficiaries. While other entities, such as employers, could adopt this scope of practice for third-party payer beneficiaries, this will not be a requirement. Payer and hospital policies could still create barriers to efficient service delivery due to a lack of state regulation.

Does the bill allow genetic counselors to order tests?

The bill, as drafted, will allow a genetic counselor to order a genetic and genomic test.

Does the bill stipulate which practitioners can provide genetic counseling?

The bill will not preclude other practitioners from providing the service if their scope of practice allows it.

How will genetic counselors be reimbursed?

As drafted, the bill will allow genetic counselors to receive 85 percent of what physicians receive under the Medicare Physician Fee Schedule. This is consistent with how Advanced Practice Nurses are reimbursed. Services will be billed as a professional service and employed genetic counselors will assign payment to the employer.

What billing codes will be utilized? 

The bill does not specifically address this issue, as CMS will determine what is most appropriate. Because Medicare’s Physician Fee Schedule does not recognize CPT code 96040, the code does not have any relative value units assigned to it as a professional fee. The service may be billed as other recognized practitioners’ bill the service today, using evaluation & management codes. As this is a likely scenario, the bill does require CMS to develop a two-digit code modifier specifically for genetic counselors. Many other services and practitioners use modifiers by adding the two digits after the main billing code. The modifier will help CMS track the utilization of genetic counselor services versus others, which should be helpful to the profession down the road. 

Does the bill change anything for states without licensure?

While the delivery of service to Medicare beneficiaries would be improved, those policies may not transfer to non-Medicare beneficiaries. Bylaws and credentialing policies at hospitals and health plans often hinge on licensure, Medicare recognition and often a combination of both. 

State licensure should still be pursued. Most, if not all, of the states pursuing licensure today do explicitly allow genetic counselors to order tests; those in states that do not allow it may want to consider amending their law.

Does the bill create special precedence for genetic counselors?

No. It was important to draft a bill in a manner that did not create any special provisions. Congress has enacted similar types of legislation for other practitioners.

When is the bill going to pass?

It is hard to say. We are in queue to receive a Congressional Budget Office (CBO) score. Congress mainly is focused on the opioid crisis as it relates to healthcare, and they will be enacting legislation throughout the year to address that issue. There may also be a mental health bill that addresses gun accessibility. Any of these measures would cost money, and our legislation, if scored as saving money, could be attached as an offset to any vehicle that spends money that would add to the federal deficit. If CBO scores the bill as a cost saver, it should move through Congress on a must-pass legislative package. The bill would be unlikely to move as a standalone bill for these reasons.

What makes you think the bill will be scored as saving money?

As the bill is written, genetic counselors will be reimbursed at 85 percent of what physicians receive. However, in the past, CBO did not always score these types of provisions as savers, because they assumed utilization increases would make up the difference. In addition, when practitioners were added, a service was usually added – this obviously cost money as utilization of a service went from zero to something. Genetic counselors are in a bit of a different situation.

CBO just scored an Occupational Therapist Assistant provision as saving money. This was something that slowed our effort down, as CBO had been working on this model for some time and the Committee wanted to see what the final score was. Our bill is a similar situation as the payment structure is the same, and a service is not being added. In addition, when scoring the bill, CBO should consider that genetic counselors will contribute to more appropriate utilization on the testing side which brings billions of dollars to the table.

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