Summary & Overview
CPT 81225: CYP2C19 Pharmacogenomic Genotyping
CPT code 81225 covers targeted molecular testing for common variants in the CYP2C19 gene, a pharmacogenomic marker that influences metabolism of several commonly prescribed medications. Nationally, CYP2C19 testing supports personalized prescribing and can affect medication selection and dosing for drugs such as certain antiplatelet agents and psychotropics, making the code relevant to payers, laboratories, and clinicians engaged in precision medicine initiatives. Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find a concise clinical context for the test, payer coverage framing, and the types of operational benchmarks and policy updates typically associated with molecular diagnostic billing. The publication outlines how CPT code 81225 is used to report targeted CYP2C19 genotyping performed in clinical laboratories, common sites of service, and the programmatic considerations payers and providers monitor for pharmacogenomic testing. Where available, the analysis highlights reimbursement patterns, documentation and lab reporting expectations, and implications for laboratory workflow and claims processing. Data not available in the input is noted where specific payer policies or taxonomies are required.
Billing Code Overview
CPT code 81225 describes a laboratory test performed by a lab analyst to detect common genetic variants in the gene cytochrome P450, family 2, subfamily C, polypeptide 19 (CYP2C19). The assay identifies clinically relevant single nucleotide variants and other common changes that affect CYP2C19 enzyme function.
Service type: Clinical molecular diagnostic test — targeted pharmacogenomic genotyping.
Typical site of service: Clinical laboratory or independent reference lab; specimens are commonly collected in outpatient clinics, hospital outpatient phlebotomy, or sent from inpatient settings to the performing laboratory.
Clinical & Coding Specifications
Clinical Context
A 52-year-old outpatient with a history of recurrent peptic ulcer disease and recent acute coronary syndrome is evaluated for pharmacogenomic-guided antiplatelet therapy. The clinician orders genetic testing for CYP2C19 variants to determine metabolizer status prior to prescribing clopidogrel. A blood or buccal swab specimen is collected in the clinic and sent to a CAP- or CLIA-certified molecular pathology laboratory. The lab performs the technical assay to detect common functional variants in the cytochrome P450 2C19 gene (CYP2C19) and generates a report indicating genotype and predicted metabolizer phenotype (e.g., poor, intermediate, normal, rapid, ultrarapid). The finalized report is transmitted to the ordering provider and incorporated into the patient’s electronic medical record to guide medication selection and dosing.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use if billing only for physician professional interpretation and report when split billing applies. |
TC |