Billing and Coding: MolDX: Pharmacogenomics Testing

Medicare covers pharmacogenomic testing when ordered to guide therapy for specific drugs with established CPIC or FDA gene/drug associations, and when documentation supports medical necessity; CYP2C9 and VKORC1 testing for warfarin must meet NCD 90.1 requirements. Billing must include the correct CPT/PLA code (or 81479 if no CPT), 1 unit of service, an appropriate ICD-10-CM code, the drug(s) under consideration in the specified claim fields, and any required MolDX forms; only one test may be billed per date of service unless additional testing is justified and documented.

"Pharmacogenomic (PGx) testing is covered when the test is ordered to guide therapy for a specific drug or drugs under consideration and when the drug(s) have established gene/drug associations docu..."

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