CPT 87040 Reimbursement Benchmarks & Policy | OpenPayer

Summary & Overview

CPT 87040: Definitive Bacterial Culture for Non-Urine/Blood/Stool Specimens

Headline: CPT 87040: Definitive Bacterial Culture for Non-Urine/Blood/Stool Specimens

Lead: CPT 87040 designates a definitive bacterial culture performed on clinical specimens other than urine, blood, or stool, reported per organism and including antimicrobial susceptibility when done. This laboratory-pathology code is central to diagnosing localized infections and guiding targeted antimicrobial therapy.

What the code represents and why it matters: CPT 87040 captures organism-level culture workups that provide definitive identification and, when performed, susceptibility results. These services inform clinical decision-making for suspected bacterial infections and support antimicrobial stewardship. Nationally, accurate coding of such cultures affects claims adjudication, laboratory utilization tracking, and antimicrobial resistance surveillance.

Key payers covered: This summary covers major commercial payers including Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare.

What readers will learn: The publication explains clinical context for CPT 87040, contrasts it with related laboratory codes (isolation/presumptive identification and susceptibility panels), and outlines typical sites of service and common clinical indications. Readers will find guidance on coding scope (per organism, inclusion of susceptibility when performed), how this code fits into laboratory service lines, and considerations for claim processing and payer coverage under major commercial plans.

Note: Data not available in the input for payer-specific reimbursement rates or state-specific policy variability.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareCPT 87040PathologyLaboratoryBacterial cultureAntimicrobial susceptibilityClinical microbiologySpecimen processingCoding guidance

CPT Code Overview

CPT 87040 describes a definitive bacterial culture from any source except urine, blood, or stool, reported per organism and including antimicrobial susceptibility testing when performed. This code applies to pathology and laboratory services and is used for identifying causative bacterial organisms from clinical specimens other than the excluded specimen types. Typical sites of service for CPT 87040 are laboratory settings, most commonly ambulatory or hospital outpatient laboratories (likely place of service 19 or 23).

Clinical & Coding Specifications

Clinical Context

A patient presents to an urgent care clinic or emergency department with fever, rigors, and hypotension. Bloodwork is obtained and the clinician orders laboratory testing to identify a possible bacterial source from a non-sterile site (for example, wound or respiratory tract) when urine, blood, and stool cultures are not indicated. A specimen (such as a wound swab, sputum, or respiratory secretions) is collected by nursing or respiratory therapy and sent to the laboratory. In the microbiology laboratory, a technologist performs a definitive bacterial culture from the submitted non-urine, non-blood, non-stool source. If an organism is isolated, identification and antimicrobial susceptibility testing are performed as part of the same workup when indicated. Results are reported to the ordering clinician to guide antimicrobial therapy and further clinical management.

Coding Specifications

Modifier 26 (Professional Component): Used when reporting only the professional interpretation or reading component of the laboratory service performed by a qualified pathologist or laboratory physician. Apply when the laboratory technical component is billed separately by the performing facility.
Modifier 90 (Reference (Outside) Laboratory): Used when the testing is performed by an outside or reference laboratory and the ordering facility bills for the service. Apply when the specimen is sent out to a third-party laboratory for definitive culture and susceptibility.
Associated provider taxonomies and specialties:

National Reimbursement Benchmarks

National commercial mean rates for 87040 cluster above Medicare when using BUCA as the composite commercial benchmark: BUCA (average commercial) mean is $11.03 while Medicare is represented as not available in the input and is therefore shown as $0.00 in the table and chart. Aetna and Cigna report the highest commercial means at $13.15 and $13.76 respectively, with Blue Cross Blue Shield and UnitedHealth Group lower at $10.26 and $8.76.

Dispersion measured by the interquartile range (P75 − P25) varies across payers. Cigna shows the widest spread (approximately 8.33), driven by a high P75 of 14.33 and a P25 of 6.00. UnitedHealth Group and Aetna show tighter distributions (ranges of 5.50 and 5.50 respectively). The table and chart below present the full breakdown of mean rates and percentiles for each payer.

State Benchmarks

State: Alaska1 / 50

Alaska Benchmarks

Alaska's reimbursement rates for CPT code 87040 show a wide spread across payers, with the highest mean rate from Aetna at $36.13 and the lowest from Cigna at $10.90. The rate spread, calculated as the difference between the 75th and 25th percentiles, is most pronounced for Blue Cross Blue Shield (BCBS), at $10.67, indicating greater variability in payments compared to other payers. Aetna's rates are tightly clustered, with all percentiles at $34.00, suggesting consistent reimbursement levels.

Compared to national averages, all Alaska payers offer substantially higher mean rates for CPT code 87040. This deviation is especially notable for Aetna and Blue Cross Blue Shield, whose mean rates in Alaska are more than double their national benchmarks. The table and chart below present the full breakdown of payer-specific rates in Alaska.

Key Insights for Alaska

Aetna is the highest paying payer for CPT 87040 in Alaska, with a mean rate of $36.13.
Cigna is the lowest paying payer, with a mean rate of $10.90.
All Alaska payer mean rates are significantly higher than their respective national averages, with Aetna and Blue Cross Blue Shield showing the largest deviations.

Related Codes

CPT-87118-AFB-DEFINITIVE-IDENTIFICATION

CPT 87118: Definitive Identification of Acid–Fast Bacilli Isolate

CPT-87084-SELECTIVE-CULTURE-COLONY-DENSITY-ESTIMATE

CPT 87084: Selective Culture with Colony Density Estimation

CPT-87150-AMPLIFIED-PROBE-ORGANISM-TYPING

CPT 87150: Amplified DNA/RNA Probe Analysis for Organism Typing

CPT-87147-IMMUNOASSAY-ON-ISOLATED-ORGANISM-TYPING

CPT 87147: Immunoassay on Isolated Organism for Typing

CPT-87153-NUCLEIC-ACID-SEQUENCING-ORGANISM-TYPING

CPT 87153: Nucleic Acid Sequencing for Organism Typing

CPT-87101-MYCOLOGY-CULTURE-SKIN-HAIR-NAIL-FUNGAL-IDENTIFICATION

CPT 87101: Mycology Culture and Identification from Skin, Hair, or Nail

CPT-87149-DNA-RNA-PROBE-ORGANISM-TYPING

CPT 87149: DNA/RNA Probe Analysis for Organism Typing

CPT-87076-ANAEROBIC-ISOLATE-DEFINITIVE-IDENTIFICATION

CPT 87076: Definitive Identification of Anaerobic Isolate

CPT-87102-FUNGAL-CULTURE-IDENTIFICATION-NONBLOOD-SPECIMENS

CPT 87102: Fungal Culture and Basic Identification of Non-Blood Specimens

87075-CULTURE-BACTERIA-EXCEPT

CPT 87075: Bacterial Culture, Excluding Blood Specimens

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Related CPT Codes

CPT Code	Description
`87070`	Culture, bacterial; any other source, with isolation and presumptive identification of isolates
`87186`	Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multi-antimicrobial agent panel
`87205`	Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types
`87880`	Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A

87070 relates as a culture procedure that includes isolation and presumptive identification; it is commonly used when isolation with preliminary ID is specifically reported and may be billed in workflows where additional isolation steps are documented.
87186 relates as a specific susceptibility testing methodology (MIC or breakpoint) and is used when detailed quantitative antimicrobial susceptibility panels are required; it may be billed in conjunction with culture workup when susceptibility testing is performed beyond routine methods.
87205 relates as a primary smear with microscopic interpretation (e.g., Gram stain) often performed on the same specimen prior to or concurrent with culture to provide rapid preliminary information; it is commonly performed together with culture services.
87880 relates as an immunoassay-based antigen detection for a specific organism (group A Streptococcus) and may be an alternative rapid diagnostic test performed on certain specimens instead of or prior to culture depending on clinical need.
Common combinations and alternatives: 87205 (smear) is commonly performed together with the culture service represented by 87040; 87186 (susceptibility) may be reported when quantitative susceptibility testing is performed in addition to culture. 87070 may be used when the reporting emphasizes isolation and presumptive identification steps rather than definitive culture reporting. 87880 is an alternative rapid test for specific pathogens and can precede culture.

`291U00000X`	Clinical Medical Laboratory
`207ZP0102X`	Pathology - Clinical Pathology
`207Q00000X`	Family Medicine Physician

Summary & Overview

CPT 87040: Definitive Bacterial Culture for Non-Urine/Blood/Stool Specimens

CPT Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes

Related Diagnoses

Related CPT Codes

National Reimbursement Benchmarks

State Benchmarks

Alaska Benchmarks

Key Insights for Alaska

Related Codes