Summary & Overview

CPT 86226: ssDNA Antibody Assay, Serum

CPT code 86226 represents a serologic laboratory assay for detecting antibodies to single-stranded DNA (ssDNA) in patient serum. As a specific immunologic test, it is used in the evaluation of autoimmune and connective tissue disorders and carries clinical importance for diagnostic workups and disease monitoring at a national level. Laboratory identification of anti-ssDNA antibodies can inform rheumatologic assessment and guide subsequent diagnostic testing.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare and Medicare. The coverage landscape for immunologic antibody testing varies across commercial plans and Medicare, affecting prior authorization requirements, medical necessity documentation, and reimbursement pathways.

Readers will find benchmark context on how this test is billed and reimbursed, a summary of payer coverage patterns, and clinical context that explains when the assay is typically ordered. The publication summarizes relevant policy considerations affecting laboratory services, outlines common modifier usage from the input list, and highlights areas where further clinical documentation or coding specificity may influence claims processing. Data not available in the input is noted where appropriate.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare86226CPTserologyautoimmune-diagnosticslaboratoryantibody-testingssDNAclinical-laboratoryimmunology

Billing Code Overview

CPT code 86226 describes a laboratory assay performed by a lab analyst to detect antibodies to single-stranded deoxyribonucleic acid (ssDNA) in a patient's serum. This test assesses the presence of anti-ssDNA antibodies, which can be used in the clinical evaluation of certain autoimmune and connective tissue disorders.

Service type: Serologic antibody assay
Typical site of service: Clinical laboratory or hospital laboratory setting

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A 34-year-old female with a history of systemic lupus erythematosus (SLE) presents to the outpatient rheumatology clinic with increased joint pain, fatigue, and a recent low-grade fever. The clinician orders autoimmune serology to assess disease activity and clarify serologic markers. A venous blood specimen is collected in the clinic phlebotomy area and sent to the hospital or reference laboratory. The laboratory analyst performs an assay to detect antibodies to single-stranded DNA (ssDNA) in the patient’s serum using immunoassay or other validated serologic techniques. Results are reported to the ordering rheumatologist and incorporated into the clinical assessment of autoimmune disease activity and differential diagnosis. Typical site of service: outpatient clinic or clinical laboratory. Service type: laboratory diagnostic serologic test.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the professional interpretation component if the laboratory separates technical and professional components.
`TC`	Technical component	Use when billing only the technical component (performed by the laboratory) when applicable.
`90`	Reference (outside) laboratory	Use when the test was performed by an outside/reference laboratory and billing reflects that circumstance.
`91`	Repeat clinical diagnostic test	Use when the test is repeated on the same day for validation or quality control purposes.
`90`	Reference (outside) laboratory	Use when the assay was performed by an independent reference laboratory.
`90`	Reference (outside) laboratory	Use when specimens are sent out to an external lab.
`52`	Reduced services	Use when the test was partially reduced or not completed as originally intended.
`53`	Discontinued procedure	Use when specimen collection or testing was discontinued for patient-related reasons.
`59`	Distinct procedural service	Not listed in provided modifiers; excluded.

Taxonomy Code	Specialty	Notes
207RH0000X	Rheumatology	Clinicians who commonly order `86226` to evaluate autoimmune disease activity.
208M00000X	Clinical Pathology	Pathologists and laboratory directors who oversee serologic testing.
207L00000X	Allergy & Immunology	Specialists who may order antibody testing for autoimmune evaluation.
207K00000X	Internal Medicine	Primary care or hospital internists who order autoimmune serologies.
363L00000X	Clinical Laboratory	Laboratory technologists and facilities performing the `ssDNA` assay.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M32.9`	Systemic lupus erythematosus, unspecified	`ssDNA` antibodies can be present in SLE and support diagnosis or assessment of disease activity.
`M35.9`	Systemic involvement of connective tissue, unspecified	Autoantibody panels including `ssDNA` help evaluate systemic connective tissue disease.
`R53.2`	Functional quadriplegia	Not directly related; excluded.
`R53.83`	Other fatigue	Fatigue is a common symptom prompting autoimmune serology including `ssDNA`.
`L93.0`	Discoid lupus erythematosus	Serologic testing including anti-DNA antibodies may be used when systemic features are suspected.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`80101`	Therapeutic drug assay, qualitative or quantitative; multiple drugs, multiple classes	May be ordered in parallel when monitoring medication levels in autoimmune patients (e.g., immunosuppressants).
`86038`	Antinuclear antibody (ANA), titer and pattern	Commonly ordered alongside `86226` as an initial screening test for systemic autoimmune diseases.
`86255`	Antibodies to double-stranded DNA (dsDNA)	Frequently ordered with `ssDNA` antibodies to further characterize anti-DNA reactivity in SLE and related disorders.
`86431`	Antibodies to extractable nuclear antigens (ENA) panel	Often performed in conjunction to identify specific autoantibodies associated with connective tissue diseases.
`99000`	Handling and/or conveyance of specimen	Administrative/handling code sometimes used for special specimen transport to reference labs where `86226` may be sent.