Summary & Overview
CPT 84234: Progesterone Receptor Assay (PRA) on Tumor Tissue
CPT code 84234 covers the progesterone receptor assay (PRA), a pathology laboratory test performed on tumor tissue—most often breast tumors—to detect the presence of progesterone receptors. Hormone receptor status is a critical determinant for systemic therapy choices in hormone-responsive cancers and influences treatment planning at a national level. Payer coverage for this molecular pathology test varies across commercial insurers and Medicare, affecting access to receptor-directed therapy decisions.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a national view of clinical context and payer considerations, outlining typical sites of service and the role of PRA in oncology care pathways.
Readers will learn: clinical purpose and settings for CPT code 84234; which major payers are relevant to coverage discussions; and what to expect in terms of the test’s role in treatment decision-making. Data not available in the input for specific reimbursement rates, CPT crosswalks, associated ICD-10 codes, or payer-specific policy language are not included.
Billing Code Overview
CPT code 84234 describes a progesterone receptor assay (PRA) performed on tumor tissue, most commonly breast tissue. The test detects progesterone receptors, which are proteins that bind the hormone progesterone and help determine tumor hormone-receptor status.
Service type: Pathology/Laboratory — tumor receptor testing
Typical site of service: Hospital outpatient laboratory, independent clinical laboratory, or pathology laboratory associated with cancer centers or surgical pathology services
Clinical & Coding Specifications
Clinical Context
A 56-year-old woman presents with a palpable breast mass or an abnormal mammographic finding. Core needle biopsy of the breast lesion is performed and tissue is sent to the pathology laboratory. The pathologist orders a progesterone receptor assay to determine expression of progesterone receptors (PRA) on tumor cells to guide adjuvant hormonal therapy decisions. In the laboratory workflow, a histology technologist prepares formalin-fixed, paraffin-embedded tissue sections; the immunohistochemistry or biochemical assay for progesterone receptor is performed by a laboratory scientist; results are reviewed and interpreted by the pathologist; a report containing the percent and intensity of receptor positivity is issued. Typical site of service: hospital outpatient laboratory, independent pathology laboratory, or hospital pathology department. Typical patient scenario: breast carcinoma staging and receptor profiling performed on tumor tissue to inform endocrine therapy eligibility and prognosis.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the pathologist interpretation separate from the laboratory technical component |
TC | Technical component |