Are PGx CPT codes covered by Medicare?

These CPT codes are recognized by Medicare, but coverage is based on medical necessity and local Medicare Administrative Contractor (MAC) policy. Documentation must support that the testing is linked to medication management or treatment decisions. Beneficiary cost-sharing (deductibles and coinsurance) may apply. Always verify coverage criteria with your local MAC before ordering.

Are the Medicare payment amounts in this guide current?

The payment amounts shown ($291.36, $450.91, $174.81) are based on the 2024 Medicare Physician Fee Schedule. Medicare fee schedules are updated annually. Always verify current payment amounts with CMS and your local MAC before making financial projections or patient estimates.

What documentation is required for PGx testing?

Documentation must support medical necessity linked to medication management or treatment decisions. This typically includes the clinical rationale for testing, the specific medications being considered, and how the test results will be used to guide treatment. Generic or standing orders without patient-specific justification may not meet coverage criteria.

Vol. 25Coding and ReimbursementEmerging Care Models

Pharmacogenomics (PGx) Testing: CPT Codes and Medicare Cost Overview

A reference guide to pharmacogenomics (PGx) testing CPT codes, Medicare allowable amounts, coverage requirements, and documentation standards — verified against the 2024 Medicare Physician Fee Schedule.

By AJ Pakpour — The Business of Modern Medicine™

AJ Pakpour infographic: Pharmacogenomics PGx testing CPT codes and Medicare cost overview — CPT 81225, 81226, 81227 with allowable amounts

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Educational Summary

Pharmacogenomics (PGx) testing analyzes how a patient's genes affect their response to medications, helping guide medication selection and dosing decisions. The three primary CPT codes for PGx testing are 81225 (cytochrome P450 2C19, $291.36), 81226 (cytochrome P450 2D6, $450.91), and 81227 (cytochrome P450 2C9, $174.81), with a combined Medicare allowable of approximately $917.08. These amounts are based on the 2024 Medicare Physician Fee Schedule and must be verified against current CMS data and local MAC policies. Coverage requires documented medical necessity linked to medication management or treatment decisions.

Key Takeaways

✓CPT 81225 (CYP2C19): Medicare allowable approximately $291.36 per 2024 fee schedule
✓CPT 81226 (CYP2D6): Medicare allowable approximately $450.91 per 2024 fee schedule
✓CPT 81227 (CYP2C9): Medicare allowable approximately $174.81 per 2024 fee schedule
✓Combined Medicare allowable for all three codes: approximately $917.08
✓Coverage is based on medical necessity and local MAC policy — documentation must support medication management decisions
✓Payment amounts are from the 2024 fee schedule and must be verified against current CMS data

Frequently Asked Questions

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The content on this page is for informational and educational purposes only. It does not constitute medical, legal, or financial advice. Medicare billing rules and program requirements are subject to change. Always consult current CMS guidance and qualified billing professionals for your specific situation.