Summary & Overview
CPT 81474: CYP2C19 Gene Analysis for Drug Metabolism
CPT code 81474 represents genetic analysis of the CYP2C19 gene, a key enzyme involved in drug metabolism. This test identifies common genetic variants that can influence how patients respond to medications, supporting personalized treatment strategies and improving clinical outcomes. The code is widely recognized in medical genetics and is typically performed in laboratory settings.
Blue Cross Blue Shield is a primary payer covered in this analysis, reflecting the code's relevance in commercial insurance policies. Readers will gain insights into payer coverage, clinical context, and policy benchmarks for genetic testing services. The publication also highlights associated taxonomies, relevant ICD-10 diagnoses, and related CPT codes, providing a comprehensive overview for stakeholders in medical genetics and laboratory medicine.
Key topics include the clinical significance of CYP2C19 testing, payer policy trends, and coding practices for laboratory-based genetic services. This summary serves as a resource for understanding the national landscape of genetic testing reimbursement and policy updates.
CPT Code Overview
CPT code 81474 is used for genetic testing of the CYP2C19 gene, which plays a critical role in drug metabolism. This test analyzes common variants such as *2, *3, *4, *5, *6, *7, *8, and *17 to help identify how an individual may process certain medications. The service type is genetic testing, and it is typically performed in a laboratory setting (Place of Service 81). This testing provides valuable information for personalized medicine and optimizing drug therapy based on genetic factors.
Clinical & Coding Specifications
Clinical Context
A patient is referred for genetic testing to evaluate their CYP2C19 gene variants, which can impact drug metabolism. This testing is commonly ordered when a patient is being considered for medications metabolized by CYP2C19, such as certain antiplatelet drugs or antidepressants. The clinical workflow involves a healthcare provider ordering the test, a specimen (such as blood or saliva) being collected, and the laboratory performing gene analysis for common CYP2C19 variants (e.g., *2, *3, *4, *5, *6, *7, *8, *17). Results are used to inform medication selection or dosing. The service is typically performed in a laboratory setting (Place of Service 81).
Coding Specifications
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Modifiers:
- Modifier
26: Used to indicate the professional component of the service, such as interpretation of the genetic test results by a qualified provider. - Modifier
TC: Used to indicate the technical component, which covers the laboratory processing and analysis of the specimen.
- Modifier
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Provider Taxonomies:
| Code | Specialty Description |
|---|---|
207SG0201X | Medical Genetics, Ph.D. Medical Genetics |
207SG0202X | Medical Genetics, Clinical Genetics (M.D.) |
207SG0203X | Medical Genetics, Clinical Biochemical Genetics |
207SG0205X | Medical Genetics, Molecular Genetics |
These taxonomies represent providers specializing in medical genetics, including clinical, biochemical, and molecular genetics.
Related Diagnoses
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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 before starting certain medications.
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Z15.89: Genetic susceptibility to other disease- Indicates the patient has a genetic predisposition to diseases, relevant when CYP2C19 variants affect drug response or disease risk.
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Z82.79: Family history of other congenital malformations, deformations and chromosomal abnormalities- Used when there is a family history that may warrant genetic testing for CYP2C19 variants.
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Z84.81: Family history of carrier of genetic disease- Relevant when testing is performed due to family history of being a carrier for genetic conditions.
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Z86.19: Personal history of other infectious and parasitic diseases- May be used if the patient's history of infectious or parasitic diseases influences the decision to perform genetic testing, though less directly related than the others.
Related CPT Codes
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81225: CYP2C19 gene analysis, common variants- Directly related to
81474, as both involve analysis of CYP2C19 gene variants. May be used as an alternative or in conjunction, depending on payer requirements or test specifics.
- Directly related to
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81226: CYP2C9 gene analysis, common variants- Used for analysis of CYP2C9 gene, another cytochrome P450 enzyme relevant to drug metabolism. Often ordered alongside
81474for comprehensive pharmacogenetic profiling.
- Used for analysis of CYP2C9 gene, another cytochrome P450 enzyme relevant to drug metabolism. Often ordered alongside
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81227: CYP2D6 gene analysis, common variants- Analyzes CYP2D6 gene variants, also important in drug metabolism. May be ordered with
81474for broader pharmacogenetic testing.
- Analyzes CYP2D6 gene variants, also important in drug metabolism. May be ordered with
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81479: Unlisted molecular pathology procedure- Used when a molecular pathology procedure does not have a specific CPT code. May be used if testing extends beyond the variants listed in
81474or involves novel methodologies.
- Used when a molecular pathology procedure does not have a specific CPT code. May be used if testing extends beyond the variants listed in
National Reimbursement Benchmarks
Nationally, Blue Cross Blue Shield and BUCA (average commercial) both reimburse CPT code 81474 at a mean rate of $80.02. Medicare data is not available in the input for this code, so a direct comparison to Medicare rates cannot be made.
Rate dispersion for both Blue Cross Blue Shield and BUCA is extremely tight, with the 25th, 50th, and 75th percentiles all at $80.00. This indicates no meaningful variation in rates across providers for these payers. The table and chart below present the full breakdown of national mean rates and percentile values for CPT code 81474.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.