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Coverage and Billing Guidance for Rapid Whole Genome Sequencing (rWGS)

Date: 10/17/25

Sunshine Health is sharing guidance from the Agency for Health Care Administration (AHCA) regarding coverage and reimbursement for rapid whole genome sequencing (rWGS) services.

Coverage Information

Florida Medicaid covers rWGS for Medicaid recipients who meet the following criteria:

  • Are 20 years of age or younger
  • Have a complex or acute illness of unknown cause that has not resulted from environmental exposure, toxic ingestion, infection with a normal response to treatment, or trauma
  • Are receiving inpatient treatment in a hospital ICU or high-acuity pediatric care unit

When this service is provided during an inpatient hospital stay, hospitals must be reimbursed separately from the inpatient diagnostic related group (DRG) payment in accordance with the 2023 General Appropriations Act.

Authorization Requirements

  • Authorizations are waived for children in an inpatient setting.
  • Sunshine Health has removed prior authorization requirements for rWGS testing for children in inpatient hospital settings.
  • Claims previously denied due to lack of authorization for dates of service beginning January 1, 2024, will be reprocessed.

Billing Instructions

To ensure accurate reimbursement, providers should bill using the CPT codes listed below. Hospitals must bill rWGS separately from the DRG payment when provided during an inpatient stay.

CPT Code    Description                              

Fee Schedule

(effective Jan. 1, 2025)

81425Test for detecting genes associated with disease, genome sequencing analysis$2,716.85
81426Test for detecting genes associated with disease, genome sequencing analysis, each additional comparator genome$1,463.37
81427Reevaluation test of previously obtained genome sequencing$1,262.33

 

For Hospital Claims:

  • Bill with Revenue Code 310 (OPH-PATHOLOGY/GENERAL) and the applicable CPT code above.
  • Prior authorization is not required.

For Independent Laboratories (PT 50):

  • Submit claims using the appropriate CPT code listed above.

Questions?

Sunshine Health has a wealth of resources available to help answer your questions and address your concerns: