Billing and Coding: Pharmacogenomic Testing

Medicare covers pharmacogenomic testing when it has established clinical utility to guide drug selection, dosing, or predict adverse reactions (including CPIC/FDA-supported gene–drug pairs), and multi-gene panels are acceptable when multiple genes are clinically indicated. Duplicate germline testing for the same genetic content in the same beneficiary is not covered unless the panel contains non-duplicative genes with established clinical utility; CPT 81418 requires testing of at least six genes including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis and specific claim-level gene documentation. CPT 81355 and 81227 are not considered reasonable for warfarin testing, and providers must follow LCD L39995 and CMS NCD guidance and include required claim documentation (e.g., gene names and drug(s) in the 2400 loop) when billing.

"Pharmacogenomic (PGx) testing is covered when results are used to guide drug selection, dosing, or to predict adverse reactions and there is established clinical utility (e."