CPT Code Overview

CPT 81416 is a genetic test that analyzes common variants in the CYP2C19 gene, which encodes a cytochrome P450 enzyme involved in drug metabolism. This assay identifies clinically relevant alleles (for example, *2, *3, *4, *5, *6, *7, *8, *17) that can affect how patients metabolize certain medications.

Service Type: Genetic Testing

Typical Site of Service: Laboratory (POS 81)

Clinical Context

A 58-year-old patient taking clopidogrel after percutaneous coronary intervention is referred for pharmacogenomic testing to assess CYP2C19 common variant status. A clinician orders the test to evaluate drug metabolism affecting antiplatelet therapy selection and dosing. The specimen is collected in the outpatient clinic and sent to a commercial molecular diagnostics laboratory (POS 81). The laboratory performs targeted genotyping for common CYP2C19 variants (for example *2, *3, *17) and issues a report that is routed to the ordering provider for medication management decisions.

Coding Specifications

• Modifiers

• 26 — Professional component: Use when billing for the interpretation and reporting performed by a qualified professional (e.g., pathologist or clinical geneticist) separate from the laboratory technical work.

• TC — Technical component: Use when billing for the laboratory technical work, including specimen processing, reagents, instrumentation, and raw data generation.

• Associated provider taxonomies and specialties

Related Diagnoses

• Z13.79 — Encounter for other screening for genetic and chromosomal anomalies

  This code applies when the patient undergoes genetic screening tests, such as targeted pharmacogenomic testing for CYP2C19 variants, as part of preventative or medication-safety evaluation.

• Z15.89 — Genetic susceptibility to other disease

  This code applies when identified genetic variants, including CYP2C19 alleles, indicate susceptibility that may influence disease risk or drug response.

• Z51.81 — Encounter for therapeutic drug level monitoring

  This code applies when pharmacogenomic results inform therapeutic monitoring or dosing decisions for medications metabolized by CYP2C19.

• F19.10 — Other psychoactive substance abuse, uncomplicated

  This code applies when evaluation of CYP2C19 may be clinically relevant to psychotropic medication metabolism in patients with substance use considerations.

• I25.10 — Atherosclerotic heart disease of native coronary artery without angina pectoris

  This code applies when CYP2C19 testing is relevant for antiplatelet therapy selection (for example clopidogrel) in patients with coronary artery disease.

Related CPT Codes

Across national benchmarks, BUCA (the composite commercial benchmark) has a mean of $8,299.75 compared with Medicare, for which no mean value is provided in the input. The available commercial payers (Aetna, Blue Cross Blue Shield, Cigna, UnitedHealth Group, and BUCA) show mean rates ranging from $6,836.09 (Aetna) to $9,544.51 (UnitedHealth Group), situating BUCA near the middle of that commercial spread.

Rate dispersion (P75 minus P25) varies notably by payer. Cigna shows a wide dispersion ($13,236.00 - $3,138.00 = $10,098.00), while Aetna is relatively tight ($9,840.00 - $1,000.00 = $8,840.00) compared with others; UnitedHealth Group and BUCA have intermediate spreads ($5,887.00 and $5,202.57, respectively). The table and chart below present the full percentile breakdown and mean rates for each payer.