How To Use CPT Code 86304

CPT 86304 describes the quantitative immunoassay for the tumor antigen CA 125, which is used as a tumor marker for pancreatic cancer. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 86304?

CPT 86304 can be used to perform a quantitative immunoassay to evaluate a patient’s serum or body fluid for the tumor antigen CA 125. This antigen is a tumor marker specifically associated with pancreatic cancer. The test measures the levels of CA 125 in the patient’s sample and provides a quantitative result.

2. Official Description

The official description of CPT code 86304 is: ‘Immunoassay for tumor antigen, quantitative; CA 125.’

3. Procedure

1. The lab analyst collects a sample of the patient’s serum or body fluid.
2. The sample is then subjected to a quantitative immunoassay using a method such as electrochemiluminescence (ECLIA).
3. The immunoassay involves reacting the specimen with test antibodies, incubating the mixture, adding microparticles to bind the complexes to an electrode, and applying an electric charge to initiate luminescence.
4. A photomultiplier measures the luminescence, and the results are reported quantitatively as a number.

4. Qualifying circumstances

CPT 86304 is typically ordered by clinicians to monitor therapy for epithelial ovarian cancer, which lines the surface of the ovaries. Serial monitoring of CA 125 levels can help track the progression of the disease and indicate possible recurrence. However, it is important to note that CA 125 tests are not specific or sensitive enough for use as screening tests in asymptomatic patients. Additionally, the test may also be used to evaluate patients with endometriosis, a condition characterized by the growth of endometrial tissue outside of the uterus, by testing peritoneal fluid.

5. When to use CPT code 86304

CPT code 86304 should be used when performing a quantitative immunoassay for the tumor antigen CA 125. It is appropriate to bill this code when evaluating a patient’s serum or body fluid sample for CA 125 levels. However, it is important to note that this code should not be used for screening purposes in asymptomatic patients.

6. Documentation requirements

To support a claim for CPT code 86304, the following documentation is required:

• Patient’s diagnosis or reason for ordering the test
• Details of the immunoassay method used, such as electrochemiluminescence (ECLIA)
• Date of the test
• Quantitative results of the CA 125 levels

7. Billing guidelines

When billing for CPT code 86304, ensure that the test is performed using a quantitative immunoassay method for the tumor antigen CA 125. It is important to follow the specific guidelines provided by the payer regarding the billing of this code. Additionally, it is important to note that some payers may require separate billing for specimen collection using a different code, such as 36415 for venous blood collection.

8. Historical information

CPT code 86304 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a history of pancreatic cancer undergoes a quantitative immunoassay for CA 125 to monitor the effectiveness of their ongoing therapy.
2. A clinician orders a CA 125 test on peritoneal fluid to evaluate a patient with suspected endometriosis.
3. A patient with a previous diagnosis of epithelial ovarian cancer undergoes serial monitoring of CA 125 levels to detect any signs of recurrence.
4. A patient with symptoms suggestive of pancreatic cancer undergoes a quantitative immunoassay for CA 125 as part of the diagnostic workup.
5. A clinician orders a CA 125 test to evaluate a patient with a family history of pancreatic cancer and concerns about their own risk.
6. A patient with a history of endometriosis undergoes a CA 125 test on peritoneal fluid to assess the severity of their condition.
7. A clinician orders a quantitative immunoassay for CA 125 to evaluate a patient with symptoms that may be indicative of pancreatic cancer.
8. A patient with a previous diagnosis of epithelial ovarian cancer undergoes a CA 125 test to monitor their response to a new treatment regimen.
9. A clinician orders a CA 125 test on peritoneal fluid to evaluate a patient with suspected complications related to endometriosis.
10. A patient with a family history of pancreatic cancer undergoes a quantitative immunoassay for CA 125 as part of a comprehensive cancer risk assessment.