2025 CPT code 86304
Effective Date: N/A Pathology and Laboratory Procedures > Immunology Procedures Feed
Immunoassay for tumor antigen, quantitative; CA 125. This test quantifies the CA 125 tumor marker in serum or body fluid.
Modifiers may apply, including 90 (Reference (Outside) Laboratory), 91 (Repeat Clinical Diagnostic Laboratory Test), and 99 (Multiple Modifiers). Check payer guidelines for appropriate use.
Medical necessity for this test is typically established by the presence of a diagnosed malignancy, particularly ovarian cancer, for monitoring purposes. It is generally not considered medically necessary for screening or initial diagnosis of ovarian cancer.
The lab analyst performs the technical aspects of the test, including sample preparation, reagent handling, and analysis using immunoassay methods. They report the quantitative results.
In simple words: This blood test measures the amount of CA 125, a substance often found in higher levels in people with ovarian cancer. It's used to track the disease and see how well treatment is working, not to diagnose it initially.
This test quantifies the CA 125 tumor marker, primarily associated with ovarian cancer, in serum or body fluid using immunoassay methods like electrochemiluminescence (ECLIA). It involves reacting the specimen with antibodies, incubation, binding complexes to an electrode, and measuring luminescence. Though not exclusively for ovarian cancer, it's commonly used to monitor treatment response and detect recurrence. CA 125 is not recommended for screening asymptomatic patients due to limited sensitivity and specificity.
Example 1: A patient with a history of ovarian cancer undergoes regular CA 125 testing to monitor for recurrence., A patient undergoing chemotherapy for ovarian cancer has CA 125 levels measured to assess treatment response., A patient with a pelvic mass has a CA 125 test performed as part of the diagnostic workup.
Documentation should include the reason for testing, relevant medical history (especially related to ovarian cancer or other malignancies), and any previous CA 125 results. For Medicare reimbursement, specific ICD-10 codes are required.
** CA 125 may also be elevated in other conditions like endometriosis and some other cancers. Its primary use remains in monitoring ovarian cancer.For Medicare patients, documentation requirements and medical necessity criteria are more stringent, requiring specific ICD-10 codes for reimbursement. The appropriateness of using this test for pancreatic cancer should be carefully considered and validated with up-to-date clinical guidelines.
- Revenue Code: T1H - LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE)
- Specialties:Oncology, Gynecology, Pathology
- Place of Service:Independent Laboratory, Hospital (Inpatient or Outpatient), Physician Office