Familial hypercholesterolemia (FH) is a common genetic cause of premature coronary heart disease that is widely underdiagnosed and undertreated. To improve the identification of FH and initiate timely and appropriate treatment strategies, genetic testing is becoming increasingly offered worldwide as a central part of diagnosis. Areas covered: Recent advances have been propelled by an improved understanding of the genetic determinants of FH together with substantially reduced costs of appropriate screening strategies. Here we review the various methods available for obtaining a molecular diagnosis of FH, and highlight the particular advantages of targeted next-generation sequencing (NGS) platforms as the most robust approach. Furthermore, we note the importance of screening for copy number variants and common polymorphisms to aid in molecularly defining suspected FH cases. Expert commentary: The need for genetic analysis of FH will increase, both for diagnosis and reimbursement of new therapies. An effective molecular diagnostic method must detect: 1) molecular and gene locus heterogeneity; 2) a wide range of mutation types; and 3) the polygenic component of FH. As availability of genetic testing for FH expands, standardization of variant curation, maintenance of clinical databases and registries, and wider health care provider education all assume greater importance.