Summary & Overview
CPT 85130: Therapeutic Anticoagulant Level Assay
CPT code 85130 denotes a laboratory test that measures the concentration of a therapeutic blood thinner in a patient specimen. This test is a component of therapeutic drug monitoring for anticoagulant agents and informs clinical dosing and safety decisions. Nationally, accurate coding and coverage for this laboratory service affect hospital and outpatient laboratory workflows, billing accuracy, and clinical management of patients on anticoagulant therapy.
Key payers addressed in typical coverage analyses include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Payer policies vary on medical necessity requirements, frequency limits, and documentation standards for therapeutic drug monitoring.
Readers will find a concise overview of the clinical context for 85130, common sites where the service is performed, and the scope of payer coverage considerations. The publication also summarizes benchmark topics such as typical utilization settings, coding nuances relevant to laboratory billing lines, and where to look for payer-specific policy language. Data not available in the input is noted where applicable. This summary is intended to support billing, coding, and revenue management teams, as well as clinical laboratory leaders seeking a national-level snapshot of the code's purpose and payer landscape.
Billing Code Overview
CPT code 85130 describes a laboratory analysis to determine the concentration of a therapeutic blood thinner in a patient specimen. This service is a therapeutic drug monitoring assay for anticoagulant medications, performed by a clinical laboratory analyst to measure drug levels and support dosing decisions.
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Service type: Laboratory therapeutic drug level testing
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Typical site of service: Clinical laboratory or hospital laboratory setting
Clinical & Coding Specifications
Clinical Context
A 68-year-old patient on warfarin presents for routine anticoagulation monitoring prior to a planned outpatient procedure. A phlebotomy specimen is obtained and sent to the laboratory where the medical technologist performs an assay to determine the concentration/effect of the therapeutic blood thinner. Results are reviewed by the laboratory analyst and reported to the ordering clinician to guide dosing adjustments, peri-procedural management, or evaluation of bleeding/thrombotic risk. Typical workflow includes specimen collection at an ambulatory clinic, emergency department, or hospital inpatient unit; transport to the clinical laboratory; performance of the therapeutic drug monitoring assay; result verification; and transmission of the verified result to the electronic health record and ordering provider. Typical site of service: hospital laboratory, independent clinical laboratory, or outpatient clinic laboratory.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the professional component of a laboratory service if the lab separates technical and professional components. |
90 | Reference (outside) laboratory |