CPT 86231 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | Pathology and Laboratory Procedures Immunology Procedures |
| Common Place of Service | 81 - Independent Laboratory 11 - Office |
| Common Modifiers | None 90 - Reference Laboratory 26 - Professional component |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 86231 |
National average reimbursement for CPT 86231 by major payers:
$10.34
$7.29
$12.36
$43.71
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
United | 86231 | $12.08 | 1255478004 - CHRISTOPHER RAIO | 111888924 - GOOD SAMARITAN HOSPTIAL MEDICAL CENTER | NY | Emergency Medicine Physician (207P00000X) |
United | 86231 | $6.53 | 1255478004 - CHRISTOPHER RAIO | 113438973 - ST JOSEPH HOSPITAL | NY | Emergency Medicine Physician (207P00000X) |
United | 86231 | $26.60 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 86231 | $12.08 | 1255478004 - CHRISTOPHER RAIO | 112050523 - ST FRANCIS HOSPITAL | NY | Emergency Medicine Physician (207P00000X) |
United | 86231 | $12.09 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 86231 | $8.92 | 1821081720 - BAYCARE HOME CARE, INC. | 593582520 - (FL) BAYCARE HOME CARE INC | FL | Home Health Agency (251E00000X) |
United | 86231 | $14.36 | 1255478004 - CHRISTOPHER RAIO | 111888924 - GOOD SAMARITAN HOSPTIAL MEDICAL CENTER | NY | Emergency Medicine Physician (207P00000X) |
United | 86231 | $12.08 | 1255478004 - CHRISTOPHER RAIO | 111635088 - MERCY MEDICAL CENTER | NY | Emergency Medicine Physician (207P00000X) |
United | 86231 | $12.09 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 86231 | $5.08 | 1366428401 - AARON ASKEW | 911750212 - DESERT BONE & JOINT SPECIALISTS, LLP | OR | Orthopaedic Trauma Physician (207XX0801X) |
United | 86231 | $7.25 | 1497944565 - MICHAEL SHULER | 581076549 - ATHENS ORTHOPEDIC CLINIC, P.A. | GA | Orthopaedic Hand Surgery Physician (207XS0106X) |
United | 86231 | $9.67 | 1164776688 - NICOLE SCHWAB | 362925195 - ALLERGY & ASTHMA OF DUPAGE, S.C. | IL | Family Nurse Practitioner (363LF0000X) |
United | 86231 | $14.36 | 1255478004 - CHRISTOPHER RAIO | 113438973 - ST JOSEPH HOSPITAL | NY | Emergency Medicine Physician (207P00000X) |
United | 86231 | $5.07 | 1609823194 - SACRED HEART HEALTH SYSTEM INC, SACRED HEART HOME CARE | 590634434 - SACRED HEART HEALTH SYSTEM INC | FL | Home Health Agency (251E00000X) |
United | 86231 | $13.30 | 1366428401 - AARON ASKEW | 931224010 - PRAXIS HEALTH, P.C. | OR | Orthopaedic Trauma Physician (207XX0801X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 86231 vs. Other Immunology Procedures Codes
The CPT 86231 code is part of the Pathology and Laboratory Procedures services used for Immunology Procedures. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 86231 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 86146-CPT | Low | Test For Blood Condition, The Test Looks For Antibodies That Are Present In Aps (Antiphospholipid) Syndrome. Aps Causes Abnormal Blood Clotting With A Low Platelet Count And Greatly Increases The Likelihood Of Miscarriage. |
| 86147-CPT | Low | Test For Blood Condition, The Test Detects Antibodies That Cause Blood To Clot Spontaneously. This Can Result In Abnormal Blood Clotting Low Platelet Counts Or Repeated Miscarriages. This Test Is Specific For Anticardiolipin Antibodies Which Are Often Present With Lupus. |
| 86225-CPT | Low | Autoimmune Disease Test, This Test Is Performed When Autoimmune Disease Involving Connective Tissue Is Suspected. The Test Identifies When An Immune System Creates Dna Antibodies To Destroy The Bodys Own Tissue. |
| 86231-CPT | Low | Test For Proteins In Gluten, Lab Test For Antibodies That May Be Elevated In Persons With Celiac Disease A Digestive Condition Caused By An Immune Reaction To Gluten. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 86231. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 86231 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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