CPT 86294 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 | 11 - Office 81 - Independent Laboratory 22 - On Campus Outpatient Hospital |
| Common Modifiers | None QW - CLIA Waived Tests 90 - Reference Laboratory 59 - Distinct Procedural Service |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 86294 |
| Medicaid Fee Schedule | View Medicaid rates for 86294 |
National average reimbursement for CPT 86294 by major payers:
$21.88
$15.53
$24.51
$36.74
CPT 86294 vs. Other Immunology Procedures Codes
The CPT 86294 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 86294 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 |
|---|---|---|
| 86294-CPT | Low | Immune Test For Tumor, This Blood Test Checks For Specific Antigens Associated With A Tumor. If Present The Antigens Will Attach To Antibodies (Immune Response). |
| 86301-CPT | Low | Cancer Treatment Assessment, This Test Helps The Doctor Determine If Cancer Of The Pancreas Or Bile Ducts Is Present. It May Also Identify Treatment Response And Whether Or Not The Cancer Has Returned. |
| 86304-CPT | Low | Cancer Treatment Assessment, This Assessment Measures Treatment Effectiveness And Identifies Whether Or Not A Cancer Has Returned. |
| 86305-CPT | Low | Ovarian Cancer Blood Test, This Test Checks A Blood Sample For Glycoprotein Which Can Help In The Diagnosis Of Ovarian Cancer. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 86294. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 86294 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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