Summary & Overview
CPT 86301: Quantitative CA 19-9 Tumor Marker Assay
CPT code 86301 designates a quantitative laboratory assay for the CA 19-9 tumor antigen, a biomarker commonly used in the evaluation and monitoring of pancreatic cancer. As a laboratory service, this code is relevant across hospital and independent clinical laboratory settings and is used in diagnostic workups, treatment monitoring, and surveillance for disease progression or recurrence. Nationally, CA 19-9 testing is an established component of oncology care pathways where tumor marker trends inform clinical decision-making.
Key payers in the national analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context and typical sites of service, plus operational details for billing and common modifier usage. The publication summarizes benchmark considerations for reimbursement and utilization, highlights pertinent policy updates affecting laboratory billing, and situates CPT code 86301 within broader laboratory service lines.
This summary is intended to inform stakeholders about the clinical role of the test, payer coverage landscape, and the kinds of benchmarks and policy points covered in the full publication. Data not available in the input is noted where relevant in detailed sections.
Billing Code Overview
CPT code 86301 reports a quantitative laboratory test measuring the tumor-associated antigen CA 19-9 in a patient’s serum or body fluid. The assay is used as a tumor marker for pancreatic cancer, typically performed by a clinical laboratory analyst.
Service Type: Clinical laboratory quantitative tumor marker assay
Typical Site of Service: Clinical laboratory or hospital laboratory (outpatient or inpatient blood/body fluid draw and lab testing)
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with a history of chronic pancreatitis presents for evaluation of progressive jaundice, weight loss, and persistent epigastric pain. The ordering clinician requests a serum tumor marker assay for CA 19-9 to aid in evaluation for possible pancreatic adenocarcinoma and to establish a baseline before advanced imaging and oncology referral. Blood is drawn in the outpatient laboratory or hospital phlebotomy unit, labeled, and sent to the clinical chemistry laboratory. The laboratory analyst performs a quantitative immunoassay for the cancer antigen CA 19-9 on serum. Results are reported in units per milliliter with the laboratory’s reference range and interpreted by the ordering provider in the context of imaging, clinical exam, and other laboratory data. Typical sites of service include outpatient laboratories, hospital outpatient departments, and inpatient hospital laboratories. Follow-up uses include monitoring response to therapy or detecting recurrence in patients with known pancreatic malignancy.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the physician or pathologist interpretation of the test result separate from the technical laboratory work |
TC |