Summary & Overview
CPT 80169: Everolimus Level Assay
CPT code 80169 represents a quantitative laboratory assay to measure everolimus levels in a patient specimen. Therapeutic drug monitoring for everolimus is clinically important for dose optimization in transplant medicine and oncology, as it helps balance efficacy against toxicity across diverse patient populations. Nationally, reimbursement and utilization of drug level assays affect outpatient and inpatient management pathways and laboratory services capacity.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find concise benchmarks for typical service settings and payer coverage patterns where available, an explanation of the clinical context for everolimus monitoring, and discussion of coding and billing considerations relevant to laboratories and clinicians. The publication highlights what constitutes the service, where it is typically performed, and which stakeholders commonly pay for it.
Data not available in the input prevents presentation of payer-specific rates, ICD-10 mappings, and related code comparisons. The content focuses on the national clinical and billing context of CPT code 80169, providing a practical reference for policy, compliance, and operational planning.
Billing Code Overview
CPT code 80169 describes a laboratory test performed on a patient specimen to determine the level of everolimus, an immunosuppressant and oncology drug. The service type is a therapeutic drug level assay (quantitative measurement of drug concentration). The typical site of service is a clinical laboratory or hospital laboratory performing specialized pharmacologic testing.
Clinical & Coding Specifications
Clinical Context
A 58-year-old solid-organ transplant recipient is seen in the transplant clinic for routine therapeutic drug monitoring. The patient is taking oral everolimus as part of an immunosuppressive regimen to prevent graft rejection. A phlebotomy is performed and the specimen is sent to the clinical laboratory for quantitation of everolimus concentration using a validated assay. Results are reviewed by the transplant clinician to assess whether the drug level is within the target therapeutic range, to guide dosing adjustments, and to correlate with clinical signs of rejection or toxicity. Typical sites of service include hospital outpatient laboratories, independent diagnostic laboratories, and ambulatory infusion or transplant clinic specimen collection areas.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the professional interpretation component if applicable (rare for drug level assays where technical component dominates). |
52 | Reduced services | Use when specimen quantity or test scope is reduced and full testing is not performed. |