2025 CPT code 86294
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Pathology and Laboratory Procedures - Immunoassay for tumor antigen Immunology Procedures Feed
Qualitative or semiquantitative immunoassay for tumor antigen (e.g., bladder tumor antigen).
Modifiers may be applicable depending on the specific circumstances of service. For instance, modifier -90 (Reference (Outside) Laboratory) might be used if the test is performed at an outside laboratory.
Medical necessity for CPT 86294 is established when the physician orders the test to monitor disease progression, evaluate treatment response, or screen for recurrence in patients with a history of specific cancers, such as bladder cancer or melanoma.Justification for the test should be documented in the patient's medical record.
The laboratory analyst performs the technical aspects of the test, including sample preparation, assay execution (e.g., ELISA), and result interpretation. The ordering physician is responsible for medical decision-making based on the results and patient clinical context.
In simple words: This lab test checks a sample of your blood or urine for a protein made by tumors.The test helps doctors track how a cancer, like bladder cancer or melanoma, is progressing. The results show if the protein is present, absent, or at what level.
This CPT code represents a qualitative or semiquantitative immunoassay used to detect the presence of a tumor antigen in a patient specimen, such as serum or urine.The test employs methods like ELISA (enzyme-linked immunosorbent assay) to identify the antigen-antibody complex. Results are reported as positive, negative, or a semiquantitative value. Clinicians may order this test to monitor disease progression in cancers like bladder cancer or melanoma.Note that for qualitative NMP22 protein, code 86386 should be used instead.
Example 1: A patient with a history of bladder cancer undergoes routine monitoring.The physician orders CPT code 86294 to assess the levels of bladder tumor antigen and evaluate treatment response., A patient presents with suspected melanoma recurrence after prior surgical resection.The physician orders CPT code 86294 to screen for the presence of melanoma-associated antigen., A patient with newly diagnosed bladder cancer undergoes a series of tests.Among these is CPT code 86294 to determine the presence of tumor antigens and aid in staging.
* Physician order specifying the requested immunoassay.* Patient demographics and relevant medical history (including cancer diagnosis and treatment).* Specimen collection documentation (date, time, type of sample).* Laboratory report with detailed results (positive, negative, or semiquantitative value).
** Payers may have specific coverage criteria for this test, often requiring prior authorization or documentation of a known tumor history. Always verify coverage with individual payers before performing the test.The test may be performed on various sample types, as appropriate.
- Revenue Code: T1H (LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE))
- RVU: Not available in provided data.RVUs vary by payer and location.
- Global Days: Not applicable. This is a laboratory test, not a surgical procedure.
- Payment Status: Active
- Modifier TC rule: Technical Component (TC) modifier is not applicable to this code, as the procedure represents the entire test process.
- Fee Schedule: Not available in the provided dataset.Consult payer-specific fee schedules for historical and current reimbursement rates.
- Specialties:Urology, Oncology, Pathology
- Place of Service:Office, Hospital (Inpatient/Outpatient), Clinical Laboratory