Florida Medicaid's Rapid Whole Genome Sequencing (RWGS) Billing Guidance Webpage
- Ask Medicaid Florida
- Dec 11, 2025
- 3 min read
Updated: Feb 22
The purpose of this article is to provide an update to the previous alerts issued on October 14, 2025 and December 21, 2023 regarding RWGS.
Florida Medicaid's Rapid Whole Genome Sequencing (RWGS) Billing Guidance Webpage
Effective January 1, 2024, the Agency for Health Care Administration (Agency) began reimbursing for rapid whole genome sequencing provided to Medicaid recipients who:
Are 20 years of age or younger;
Have a complex or acute illness of unknown etiology that has not been caused by environmental exposure, toxic ingestion, an infection with normal response to treatment, or trauma, and;
Are receiving inpatient treatment in the high-acuity pediatric care unit of a hospital ICU.
Important Coverage Requirements for Providers
The Agency issued a Statewide Medicaid Managed Care (SMMC) Policy Transmittal (PT) on October 15, 2025 directing all SMMC health plans to waive prior authorization for children under 21 years. The PT can be found at this link: PT-2015-16.
Hospital providers will be reimbursed the additional maximum fee schedule amount in addition to inpatient reimbursement for diagnostic-related group (DRG) payment.
Key Details for Billing
Eligible Recipients: Medicaid recipients 20 or younger with an acute, complex, unknown-etiology illness in an ICU/high-acuity unit.
CPT Codes: 81425 (initial), 81426 (each additional), 81427 (reevaluation).
Billing for Hospitals: Use Revenue Code 310 (Pathology/General) in addition to CPT codes, reimbursed on top of DRG payment.
Billing for Labs: Use CPT codes 81425, 81426, 81427 on the independent lab fee schedule.
Date of Service: Must be on or after January 1, 2024.
Prior Authorization: Not required.
Documentation: Submit supporting documentation for medical necessity with the claim.
The Agency’s new web page on RWGS has been updated to include links for all of the individual SMMC plans that explains their billing guidance, a well as FFS guidance and links to applicable handbooks, fee schedules and Medicaid policies.
For additional information regarding these changes please visit: Rule 59G-4.150, F.A.C., Inpatient Hospital Services Coverage Policy, and Rule 59G-4.190, F.A.C., Laboratory Services Coverage Policy.
Other Facts about Rapid Whole Genome Sequencing
How much does rapid whole genome sequencing cost?
There are many providers that offer whole genome sequencing tests in the United States; many of them offer prices that range from $999 to as low as $399.
Will insurance pay for whole genome sequencing?
Insurance carriers are increasingly covering exome and genome testing. But as with all medical tests, patients may still receive a bill if they have not yet met their yearly plan deductible or if their plan requires coinsurance.
How much does Medicaid pay for genetic testing?
Medicaid generally covers medically necessary genetic testing with $0 out-of-pocket costs for patients, but coverage varies significantly by state, the specific test (e.g., BRCA, whole exome), and clinical criteria, often requiring pre-authorization and meeting specific medical necessity rules. While some tests like BRCA or Lynch syndrome are often covered if criteria are met, multi-gene panels might not be, so checking your specific state's Medicaid guidelines is crucial.
Key Factors Influencing Coverage
State-Specific Policies: Each state's Medicaid program sets its own rules for genetic testing.
Medical Necessity: Tests must be deemed medically necessary for diagnosis or treatment, not just for screening or information.
Clinical Criteria: You usually need a personal or family history of certain conditions (like specific cancers) to qualify.
Pre-Authorization: Many tests require prior approval from Medicaid.
Commonly Covered Tests (with criteria)
BRCA1/BRCA2 Testing: Often covered for individuals with strong family histories of breast/ovarian cancer.
Lynch Syndrome Testing: Frequently covered for those with family histories of colon, uterine, or ovarian cancers.
Whole Exome/Genome Sequencing: May be covered in specific cases where other tests aren't sufficient.
Tests That May Not Be Covered
Tests for screening without symptoms.
Tests done solely for informational purposes (e.g., paternity).
Some multi-gene panels.
How to Find Out What Your Medicaid Covers
Talk to Your Doctor:
They can determine if a test is medically necessary and what might be covered.
Contact Your State Medicaid Office:
Use resources like the Genetics Policy Hub or ASCO's State Medicaid & CHIP Profiles page to find your state's specific policies.
Disclaimer
This information was provided by the Agency for Healthcare Administration (AHCA). The "Ask Medicaid Florida" website is intended for informational purposes only. "Ask Medicaid Florida" is not associated with any state agency including Medicaid Florida. Find all AHCA archived alerts here. Please feel free to read our full disclaimer here. If you have received this message in error, please immediately notify us at info@askmedicaidflorida.com and delete the original message. We regret any inconvenience and appreciate your cooperation.
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