Lack of consistent insurance coverage for genetic counseling services billed under Current Procedural Terminology (CPT) code 96040 creates a barrier for access to this service. This retrospective study examined coverage and reimbursement for reproductive genetic counseling encounters billed under CPT code 96040 as a professional fee over an eight-year period at Rutgers Robert Wood Johnson Medical School, a regional perinatal center in New Jersey, a state requiring licensure. Descriptive statistics were tabulated to assess the disparity between Medicare/Medicaid, Managed Care Medicaid, and commercial insurance payers, including how often encounters were covered and if reimbursed, at what percentage of the amount billed. A comparison of individual plan types (Health Maintenance Organization, Point of Service, and Preferred Provider Organization) was carried out. Overall trends in reimbursement were assessed across payers. The study found 61% of 60-min encounters billed to Medicare/Medicaid, Managed Care Medicaid, and commercial insurance payers received coverage. Of all covered 60-min encounters billed to Managed Care Medicaid and commercial insurance payers, an average of 36% of the amount billed was reimbursed. Medicare/Medicaid encounters were never reimbursed. Commercial insurance covered 65% of encounters billed but this varied between payers. Across all payers, an overall downward trend of reimbursement was demonstrated over the eight-year period. Lack of consistent service coverage creates a barrier and patients cannot universally access genetic counseling services. Steps to improve coverage need to include passing of legislation, notably the next bill to replace the former H.R. 3235, ‘Access to Genetic Counselor Services Act of 2019’ and provisions within third-party payers that allow for credentialing of genetic counseling providers.

中文翻译：

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2010 年至 2018 年新泽西州多方支付者对生殖遗传咨询的覆盖和报销趋势

根据现行程序术语 (CPT) 代码 96040 计费的遗传咨询服务缺乏一致的保险范围，这为获得该服务造成了障碍。这项回顾性研究检查了在新泽西州的地区围产中心罗格斯罗伯特伍德约翰逊医学院（Rutgers Robert Wood Johnson Medical School）八年期间根据 CPT 代码 96040 作为专业费用计费的生殖遗传咨询的覆盖范围和报销，该州需要执照。描述性统计数据被制成表格，以评估医疗保险/医疗补助、管理式医疗医疗补助和商业保险支付者之间的差异，包括承保的频率以及如果报销，按账单金额的百分比计算。个人计划类型的比较（健康维护组织、服务点、和首选提供者组织）。跨付款人评估了报销的总体趋势。该研究发现，在向 Medicare/Medicaid、Managed Care Medicaid 和商业保险支付者计费的 60 分钟遭遇中，有 61% 获得了保险。在向 Managed Care Medicaid 和商业保险支付者计费的所有 60 分钟遭遇中，平均 36% 的计费金额得到了报销。医疗保险/医疗补助遭遇从未得到报销。商业保险涵盖了 65% 的收费遭遇，但付款人之间的情况各不相同。在所有付款人中，报销的总体下降趋势在八年期间表现出。缺乏一致的服务覆盖范围造成了障碍，患者无法普遍获得遗传咨询服务。提高覆盖率的步骤需要包括通过立法，