CPT 81425 Reimbursement Benchmarks | OpenPayer

Summary & Overview

CPT 81425: Genome Sequencing for Unexplained Heritable Disorders

CPT code 81425 represents genome sequencing for patients with unexplained constitutional or heritable disorders, a critical tool in modern medical genetics. This procedure enables comprehensive analysis of a patient's genetic makeup, supporting diagnosis and management of complex syndromes and conditions. Nationally, genome sequencing is increasingly recognized for its role in identifying rare genetic disorders, guiding treatment decisions, and informing family planning.

Key payers covered in this publication include Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare. The report provides an overview of payer coverage, clinical benchmarks, and policy updates relevant to genome sequencing procedures. Readers will gain insight into the clinical context of 81425, including its use in laboratory settings, and understand how this code fits within broader genomic testing practices. The publication also addresses related codes, common modifiers, and associated taxonomies, offering a comprehensive resource for stakeholders interested in medical genetics billing and policy trends.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 81425genome sequencingmedical geneticslaboratory proceduresgenomic assayspathologyclinical geneticsbilling codespolicy updatesmolecular diagnostics

CPT Code Overview

CPT code 81425 is used to report genome sequencing procedures performed for patients with unexplained constitutional or heritable disorders or syndromes. This code falls under Pathology and Laboratory Procedures, specifically Genomic Sequencing Procedures and Other Molecular Multianalyte Assays. The typical site of service for this procedure is a laboratory (POS 81), where advanced genetic testing is conducted to identify potential genetic causes of complex medical conditions.

Clinical & Coding Specifications

Clinical Context

A patient presents with unexplained constitutional or heritable disorders, such as developmental delays, congenital malformations, or suspected genetic syndromes. The clinical workflow involves the ordering provider, often a medical geneticist, requesting a comprehensive genome sequencing procedure (81425) to identify potential genetic causes. The specimen is collected and sent to a specialized laboratory (Place of Service 81), where the sequencing and analysis are performed. Results are interpreted by professionals with expertise in medical genetics, and findings are reported back to the provider for further clinical management.

Coding Specifications

Modifiers:
- Modifier 26: Used when billing for the professional component, which includes interpretation and reporting of the genomic sequencing results.
- Modifier TC: Used when billing for the technical component, which covers the laboratory processing and sequencing of the genome.
Provider Taxonomies:

Taxonomy Code Specialty Name

National Reimbursement Benchmarks

Nationally, the mean rate for CPT code 81425 among commercial payers (BUCA average) is $3,452.65, which is substantially higher than the Aetna mean rate of $1,097.89. Blue Cross Blue Shield, Cigna, and UnitedHealth Group all report mean rates above $3,600, with UnitedHealth Group at $3,979.18, the highest among the listed payers.

Rate dispersion varies significantly across payers. Blue Cross Blue Shield shows a range of $3,328.81 between its 75th and 25th percentiles, indicating a wide spread in contracted rates. Cigna's range is even larger at $4,250.00, while UnitedHealth Group's range is $2,465.00. BUCA's range is $2,558.09. Aetna stands out with all percentile values at $0.00, reflecting either a lack of contracted rates or data limitations for this code.

The table and chart below present the full breakdown of national mean rates and percentile distributions for each payer.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska exhibits a wide rate spread for CPT code 81425, particularly among major commercial payers. The difference between the 75th and 25th percentiles (rate spread) is most pronounced for Blue Cross Blue Shield ($2,100.40) and Cigna ($3,362.00), while UnitedHealth Group shows a narrow spread ($744.00), indicating less variability in their reimbursement rates. Aetna's 25th and 50th percentiles are both $0.00, suggesting limited or no payment for a significant portion of providers, with a jump at the 75th percentile.

Compared to national averages, Alaska's mean rates for all payers are substantially higher, with UnitedHealth Group's mean rate in Alaska more than double its national mean. The table and chart below present the full breakdown of payer-specific rates for Alaska, highlighting the significant regional variation in reimbursement for CPT code 81425.

Key Insights for Alaska

UnitedHealth Group is the highest paying payer in Alaska for CPT 81425, with a mean rate of $9,093.69.
Aetna is the lowest paying payer in Alaska, with a mean rate of $3,665.10.
All Alaska payer mean rates are significantly higher than their respective national averages, with UnitedHealth Group's mean rate more than double the national mean.

CPT 81458: Genomic Sequence Analysis Panel for Solid Organ Neoplasms

81455-SOLID-ORGAN-OR-HEMATOLYMPHOID-NEOPLASM-OR-DISORDER-51-OR

CPT 81455: Genomic Sequencing Panel for 51+ Gene Neoplasm Analysis

81450-81450-TARGETED-GENOMIC-SEQUENCE-ANALYSIS-PANEL

CPT 81450: Targeted Genomic Sequence Analysis for Hematolymphoid Neoplasms

81427-THE-LAB-ANALYST-REEVALUATES-AN-EXISTING-PATIENT-FULL

CPT 81427: Reevaluation of Full Genomic Sequence Analysis

81448-HEREDITARY-PERIPHERAL-NEUROPATHIES-PANEL-EG

CPT 81448: Hereditary Peripheral Neuropathy Genomic Sequence Analysis Panel

81416-CYP2C19-CYTOCHROME-P450-FAMILY-2-SUBFAMILY-C-POLYPEPTIDE-19

CPT 81416: CYP2C19 Gene Analysis, Common Variants

81431-HEARING-LOSS-DUPDEL

CPT 81431: Genomic Sequencing for Hearing Loss Duplication/Deletion Analysis

81435-HEREDITARY-COLON-CANCER-DISORDERS-EG-LYNCH-SYNDROME-PTEN

CPT 81435: Genetic Panel for Hereditary Colon Cancer Disorders

81411-APOLIPOPROTEIN-E-APOE-GENE-ANALYSIS-COMMON-VARIANTS-EG-E2

CPT 81411: Apolipoprotein E (ApoE) Gene Analysis

81449-GENOMIC-SEQUENCING-PROCEDURES-AND-OTHER-MOLECULAR

CPT 81449: Targeted Genomic Sequence Analysis Panel, Solid Organ Neoplasm, RNA

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OpenPayer

Summary & Overview

CPT 81425: Genome Sequencing for Unexplained Heritable Disorders

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes