CPT Code Overview

CPT code 81461 is used to report genetic testing for the CYP2C19 gene, which is part of the cytochrome P450 family. This test analyzes common variants such as *2, *3, *4, *5, *6, *7, *8, and *17 to assess drug metabolism. The service type is genetic testing, typically performed in a laboratory setting (Place of Service 81). This testing provides valuable information for understanding individual responses to medications and optimizing therapeutic strategies.

Clinical Context

A patient is referred for genetic testing to evaluate their CYP2C19 gene variants, which influence drug metabolism. This testing is typically ordered when a patient is being considered for medications metabolized by CYP2C19, such as certain antiplatelet agents or antidepressants, to guide therapy and reduce adverse drug reactions. The workflow involves a physician (e.g., internal medicine, family medicine, or genetics specialist) ordering the test, sample collection (usually blood), and laboratory analysis in a facility designated as Place of Service 81 (Laboratory). Results are interpreted by a qualified provider, and findings may inform medication selection or dosing.

Coding Specifications

• Modifiers:

  • 26: Professional Component – Used when only the interpretation of the test is performed by the provider, not the laboratory analysis.
  • TC: Technical Component – Used when only the laboratory performs the technical aspects of the test, not the interpretation.

• Provider Taxonomies:

These specialties represent providers who may order, interpret, or perform CYP2C19 genetic testing.

Related Diagnoses

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

  • Used when the test is performed as a screening for genetic variants, such as CYP2C19, before starting certain medications.

• Z15.89: Genetic susceptibility to other disease

  • Indicates the patient has a genetic predisposition to disease, relevant when CYP2C19 variants affect drug response or disease risk.

• Z51.81: Encounter for therapeutic drug level monitoring

  • Used when genetic testing is part of monitoring drug levels to optimize therapy, especially for drugs metabolized by CYP2C19.

• Z79.899: Other long term (current) drug therapy

  • Relevant for patients on chronic medications where CYP2C19 testing may inform ongoing therapy.

• R79.89: Other specified abnormal findings of blood chemistry

  • Used when abnormal blood chemistry findings prompt genetic testing to investigate underlying causes, such as altered drug metabolism.

Related CPT Codes

• 81225: CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants

  • Used for testing CYP2C9 gene variants, often alongside CYP2C19 to assess drug metabolism for medications affected by both enzymes.

• 81226: CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants

  • Used for CYP2D6 gene analysis, which may be ordered with CYP2C19 for comprehensive pharmacogenetic profiling.

• 81479: Unlisted molecular pathology procedure

  • Used when a molecular pathology procedure does not have a specific CPT code; may be an alternative if testing is outside the scope of defined codes.

• 81227: CYP3A4 (cytochrome P450, family 3, subfamily A, polypeptide 4) (e.g., drug metabolism), gene analysis, common variants

  • Used for CYP3A4 gene analysis, which may be performed with CYP2C19 testing for broader drug metabolism assessment.

These codes are commonly used together for multi-gene pharmacogenetic panels or as alternatives when specific gene testing is required.

For CPT code 81461, the national mean rate for Blue Cross Blue Shield and BUCA (average commercial) is $80.02. Medicare rates are not available in the input for comparison. The mean rates for both commercial payers are identical, indicating a uniform reimbursement landscape at the national level.

Rate dispersion is minimal across both Blue Cross Blue Shield and BUCA, with the 25th, 50th, and 75th percentiles all at $80.00. This suggests extremely tight pricing with no variation between the lower and upper quartiles. The table and chart below present the full breakdown of national benchmarks for each payer.