Genetic Counseling & Risk Assessment

Recommendation:

A risk assessment and genetic counseling program is available for patients at risk for familial or hereditary cancer syndromes to educate patients about their chance of developing cancers, help them obtain personal meaning from cancer genetic information, and empower them to make educated, informed decisions about genetic testing, cancer screening, and cancer prevention.

Overview

Risk assessment and genetic counseling refers to identifying patients at increased risk of developing cancer because of a personal or family history of cancer or a known hereditary cancer syndrome. This information can have a powerful effect on early detection and cancer outcome; it also has an effect on medical management and prevention. Cancer risk assessment and genetic counseling are rapidly becoming standards of care for patients with personal and/or family history of cancer who are at high risk of having a hereditary syndrome. Patients can be identified in both the inpatient and outpatient setting. Nurses in all areas of practice can be instrumental in exploring a patient’s family history of cancer, identifying patients who may be at-risk based on family history, and referring them for further discussion to the genetics department.

Genetic counseling can be performed by an Advanced Practice Nurse (APN) in genetics and/or oncology, Advanced Genetics Nursing Board Certified (AGN-BC), a Genetics Clinical Nurse (GCN), a board certified physician, or genetic counselor. The healthcare professional should have experience and an educational background in genetics and cancer genetics, counseling and hereditary cancer syndromes, to provide accurate risk assessment and empathetic genetic counseling to patients and their families. The healthcare professional not only provides risk assessment and genetic counseling they also determine the appropriateness of genetic testing, choose the most appropriate test, interpret the test results, and provide guidance for screening and prevention.

The Commission on Cancer and the National Accreditation Program for Breast Centers each require accredited programs to have a risk assessment and genetic counseling process.

Standards/Accreditation/Credentials

Organizations for certification or licensure, and/or membership organizations for this discipline:

Genetics Clinical Nurse (GCN) or Advanced Genetics Nursing-Board Certified (AGN-BC), Certified Genetic Counselor (CGC)

Resources to Help

Caseload Benchmarks

Caseload benchmarks for genetic testing ranges between 10-15 patients monthly, which includes pre-test counseling and post-test results disclosure at a separate visit. Caseload challenges include getting referrals from the referring physician, paperwork specific to counseling as well as insurance authorizations, and patient failure to make scheduled appointments.

Most of insurance companies cover genetic testing, including Medicare and Medicaid. The genetic labs actually pre-certify testing because they bill for the actual test. Charging for counseling is not a problem. A nurse genetics counselor describes the process at her cancer program as follows:

Our cancer program screens all new patients coming through the cancer center with a short questionnaire to identify patients that meet the NCCN (National Comprehensive Cancer Network) guidelines for testing as well as reviewing all cancer pathology that meets criteria performed in our facility. If patients meet criteria a user-friendly, short referral form is forwarded to the patient’s physician. Education to medical providers is very important. I provide this periodically via a variety of venues: symposia, 5th Friday noon conferences, as a member of the Cancer Conference (tumor boards), articles, and by visiting offices. <

Genetic counseling can be provided in a variety of models for service delivery depending on the provider’s level of expertise. Some genetic counselors evaluate multiple types of genetic cases, i.e., cancer, pediatrics, prenatal, cardiac, etc., while others provide counseling for one specific area. Some provide all the care from marketing, educating the community and providers, performing the actual assessment, collecting the specimen, to post-education while others may have a team to even the work load.

Insurance Considerations

ICD-10 Codes Z84.89 HCPCS codes 99211-99245

A nurse counselor reports:  I bill 99211 but a NP can bill a 99213 or 14. Usually not a 99215 level. CPT code (96040) to cover genetic counseling visits provided by Certified Genetic Counselors only (CGC).

The Affordable Care Act preventive services for women include counseling and testing for BRCA mutation in women at “higher risk” without co-pay or co-insurance. Some programs are able to offer free evaluations and some genetics laboratories offer financial assistance or even free testing to those that are underinsured or uninsured.

 
ACCC Member Program: CHRISTUS St. Michael, Texarkana, Texas

CHRISTUS St. Michael’s Clinic launched its patient hereditary cancer risk program in 2011.  Within four years, over 300 patients were provided cancer risk assessment and genetic counseling.

The overall goal of the navigation program is to ensure seamless and coordinated care among the physicians, the diagnostic tests, and the cancer treatments, while offering education, support, and guidance to help patients and families cope with their challenges.

Genetics Nurse Type: Masters-level Registered Nurse (RN) with Genetic Clinical Nurse (GCN) credentialing.

Genetics Educator’s Duties:

  • Collecting relevant information needed to assess a patient’s personal and family history of cancer
  • Evaluating a patient’s risk of developing cancer
  • Educating patients about suspected hereditary cancer syndromes
  • Obtaining an order from a healthcare provider
  • Obtaining informed consent for genetic testing
  • Post-test counseling to include disclosure of genetic test results, significance and impact of the test results, medical management options, informing other relatives, future contact, and available resources.