CPT 81235 EGFR Testing Reimbursement & Policy

CPT code 81235 represents laboratory-based molecular testing for common alterations in the epidermal growth factor receptor (EGFR) gene. EGFR testing is clinically important for identifying patients who may benefit from targeted therapies in oncology, especially non-small cell lung cancer and other EGFR-driven tumors. Nationally, standardized billing and accurate coding for EGFR assays support appropriate clinical decision-making and payer coverage determinations.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The summary highlights payer coverage patterns and common reimbursement considerations for molecular diagnostic services.

Readers will find a concise overview of the clinical context for EGFR testing, typical sites of service, and the type of laboratory procedure captured by this CPT code. The publication also outlines benchmarks and policy-relevant issues affecting molecular diagnostic billing, including coverage drivers and documentation considerations. Where input data is incomplete, the text notes that specific items are not available in the input.

Billing Code Overview

CPT code 81235 describes a laboratory test that detects common alterations in the epidermal growth factor receptor (EGFR) gene. The procedure involves analysis of patient specimens by a laboratory analyst to identify actionable genetic changes in EGFR that can inform targeted therapies.

Service type: Molecular diagnostic testing (laboratory-based genetic analysis)
Typical site of service: Clinical laboratory or reference molecular pathology laboratory, with specimen collection commonly performed in outpatient settings or hospital collection areas.

Data not available in the input.

Clinical Context

A 64-year-old patient with newly diagnosed non–small cell lung cancer (adenocarcinoma) presents to oncology for molecular profiling to guide targeted therapy selection. The oncologist orders epidermal growth factor receptor testing to detect common activating mutations (exon 19 deletions, L858R, and other common EGFR alterations). A blood sample (plasma cfDNA) or a formalin-fixed paraffin-embedded tumor specimen is collected and sent to the molecular pathology laboratory. The laboratory performs the technical sequencing or PCR-based assay to detect EGFR variants and generates a report that is routed to the ordering oncologist. Results inform eligibility for EGFR tyrosine kinase inhibitors and subsequent treatment planning. Typical sites of service include hospital outpatient laboratories, independent clinical laboratories, and hospital inpatient laboratories processing specimens from admitted oncology patients.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use if reporting the professional (interpretive) component separately when a billing split between technical and professional components occurs.
`TC`	Technical component	Use when billing only the technical component (laboratory processing and analysis) performed by the laboratory.

Taxonomy Code	Specialty	Notes
207RG0100X	Anatomic and Clinical Pathology	Molecular pathology and laboratory medicine specialists oversee EGFR testing.
207RH0000X	Hematopathology	Laboratories with molecular diagnostics often include hematopathology expertise for complex sample handling.
208000000X	Medical Oncology	Ordering clinicians who interpret results for targeted therapy selection.
207L00000X	Pathology	General pathology oversight for testing, specimen adequacy, and result sign-out.
261QM0800X	Clinical Molecular Genetics	Specialists in molecular genetics who validate and interpret EGFR variant findings.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`C34.90`	Malignant neoplasm of unspecified part of unspecified bronchus or lung	Primary lung cancer diagnosis commonly prompting EGFR mutation testing to determine targeted therapy.
`C34.11`	Malignant neoplasm of upper lobe, right bronchus or lung	Site-specific lung cancer where EGFR testing is standard for adenocarcinoma histology.
`C34.12`	Malignant neoplasm of middle lobe, right bronchus or lung	Lung cancer location; molecular testing guides systemic therapy.
`C34.31`	Malignant neoplasm of upper lobe, left bronchus or lung	Common anatomical code associated with NSCLC for which EGFR testing is indicated.
`Z85.118`	Personal history of malignant neoplasm of bronchus and lung	Surveillance contexts may trigger molecular testing on recurrent or metastatic disease specimens.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`81235`	EGFR (epidermal growth factor receptor) gene analysis, common variants	Primary molecular test detecting common EGFR alterations used to guide therapy selection.
`81275`	BRAF (v-raf murine sarcoma viral oncogene homolog B1) gene analysis, common variants	Often ordered in parallel for comprehensive molecular profiling in lung adenocarcinoma when broader mutation testing is indicated.
`81445`	Oncology (panel) multigene sequencing, for solid tumor panel, 5-50 genes	Used when broader next-generation sequencing panel is performed that may include EGFR among other actionable genes.
`88384`	Immunohistochemistry, per antibody stain	May be performed on tissue to assess protein expression of markers complementary to genetic testing.
`0000U`	Data not available in the input.	Data not available in the input.

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Summary & Overview

CPT 81235: EGFR Gene Mutation Detection, Laboratory Analysis