2025 CPT code 86316
(Active) Effective Date: N/A Revision Date: N/A Pathology and Laboratory Procedures - Qualitative or Semiquantitative Immunoassays Immunology Procedures Feed
Immunoassay for tumor antigen; other antigen, quantitative (e.g., CA 50, 72-4, 549), each.
Modifiers may be applicable, especially those related to the place of service, multiple procedures, or technical components. Consult the most recent CPT guidelines and payer-specific instructions for appropriate modifier usage.
Medical necessity for this code is highly dependent on clinical context.It is generally considered medically necessary for monitoring known malignancies when guided by established treatment protocols and clinical judgment.For diagnostic purposes, it may require additional clinical justification or preauthorization depending on the payer, and it is usually not recommended for screening purposes for asymptomatic patients.
The clinical responsibility lies with the laboratory analyst who performs the technical aspects of the immunoassay, including specimen preparation, reagent handling, instrument operation, data analysis, and result reporting.The ordering physician is responsible for appropriate medical decision-making based on the results.
In simple words: This lab test measures the amount of specific proteins (tumor antigens) in a blood or body fluid sample. These proteins are made by tumors or the body's response to them.The test helps doctors monitor how cancer is progressing and whether treatment is working. It's not used for screening.
This CPT code reports a quantitative immunoassay used to measure the levels of tumor antigens in a patient's specimen.The test may utilize methods such as ELISA to detect various tumor markers, including but not limited to CA 50 (pancreatic cancer), CA 72-4 (stomach or ovarian cancer), and CA 549 (breast cancer).The results are reported as a quantitative value, aiding in monitoring disease progression, treatment effectiveness, and recurrence in patients with specific malignancies. Note that these markers are not suitable for cancer screening.
Example 1: A patient with known pancreatic cancer undergoes regular monitoring of CA 50 levels using this code to assess treatment response.Serial measurements over time help determine if the cancer is progressing or responding to treatment., A patient presents with suspected ovarian cancer. A CA 72-4 test, billed using this code, is ordered to assist in diagnosis and staging. High levels would suggest further investigation is warranted., Post-surgical follow-up of a patient with breast cancer involves regular monitoring of CA 549 levels (using this code) to detect potential recurrence. Low levels after initial treatment indicate disease response.
** Many payers consider this code experimental/investigational unless used in specific circumstances; for example, Chromogranin A testing for carcinoid tumors may be an exception.Always verify payer-specific coverage and medical necessity policies before billing.
- Revenue Code: T1H (LAB TESTS - OTHER (NON-MEDICARE FEE SCHEDULE))
- RVU: RVUs vary depending on several factors including geographic location, facility type, and payer. Consult your local fee schedule for specific values.Note:This code may have different RVU values than more specific tumor marker assays.
- Payment Status: Active, but payment may vary widely based on payer policies and medical necessity considerations. Often considered investigational or experimental unless used for specific scenarios like Chromogranin A in carcinoid tumors.
- Modifier TC rule: The TC modifier may be applicable depending on the clinical situation.Consult the CPT manual and payer guidelines for specific requirements.
- Fee Schedule: Historical fee schedule data will vary by payer, location, and year. Refer to relevant fee schedules to obtain historical values.
- Specialties:Oncology, Pathology, Hematology, Internal Medicine
- Place of Service:Office, Hospital (Inpatient and Outpatient), Laboratory