Billing and Coding: Pharmacogenomics Testing

Medicare covers pharmacogenomics testing when it is reasonable and necessary per LCD L39063; CPT 81418 requires testing of at least six genes including CYP2C19 and CYP2D6 with duplication/deletion analysis and the names of tested genes must be reported on the claim. Duplicate germline testing of the same genetic content in the same beneficiary is not covered unless non-duplicative components have established clinical utility; CPT 81355 and 81227 are not covered for warfarin testing and non-covered services must be billed with the appropriate modifier.

"Pharmacogenomics (PGx) testing is covered when it is reasonable and necessary per LCD L39063 and Medicare coverage rules for the beneficiary's clinical indication."

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