Summary & Overview
CPT 86695: HSV-1 Antibody Immunoassay in Serum or CSF
CPT code 86695 represents a laboratory immunoassay to detect antibodies to herpes simplex virus type 1 (HSV‑1) in serum or cerebrospinal fluid. As a commonly ordered infectious disease serology test, it plays a role in diagnosing HSV‑1 infection and informing clinical decisions for neurologic and mucocutaneous presentations. Nationally, accurate coding of serologic assays such as CPT code 86695 affects claims processing, lab reimbursement, and surveillance data used by public health entities.
Key payers considered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for the assay, common sites of service, and the typical service type. The publication summarizes payer coverage patterns, coding and billing considerations relevant to outpatient and inpatient laboratory settings, and benchmarking points where available. It also highlights policy and documentation elements that commonly influence reimbursement decisions for HSV‑1 antibody testing.
This briefing is intended for laboratory managers, coding and billing staff, clinician leaders, and policy analysts seeking a national-level reference on CPT code 86695, its clinical utility, and the factors that commonly affect payer adjudication and reporting for serologic HSV‑1 testing.
Billing Code Overview
CPT code 86695 describes an immunoassay performed by a laboratory analyst to detect antibodies to herpes simplex virus type 1 (HSV‑1) in a patient’s serum or cerebrospinal fluid (CSF). This test evaluates the presence of HSV‑1–specific antibodies, which can support diagnosis of current or prior infection and help guide clinical management when virologic testing or clinical presentation suggests herpes simplex involvement.
Service Type: Laboratory diagnostic immunoassay
Typical Site of Service: Clinical laboratory or hospital laboratory processing serum or CSF specimens
Clinical & Coding Specifications
Clinical Context
A 28-year-old immunocompetent adult presents to the emergency department with acute onset fever, headache, photophobia, and altered mental status. The treating emergency medicine physician suspects viral encephalitis; a lumbar puncture is performed and cerebrospinal fluid (CSF) is sent to the hospital laboratory. Concurrently, a serum sample is obtained because the clinician requests serologic testing for herpes simplex virus type 1 antibodies to support the diagnosis of recent or prior HSV-1 infection. In the clinical workflow, the specimen is accessioned by the laboratory, and a medical technologist or lab analyst performs an immunoassay to detect HSV-1 IgM and/or IgG in serum or CSF. Results are reviewed by a pathologist or laboratory director (professional component) and the instrument/kit processing (technical component) is billed. Turnaround time depends on lab protocols; positive findings for HSV-1 antibodies can support a diagnosis of HSV-1 CNS infection when correlated with clinical presentation and PCR results. This test is typically ordered in acute care hospitals, outpatient laboratories, and specialty infectious disease clinics; typical site of service is hospital laboratory or independent clinical laboratory.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the professional interpretation or result review by the pathologist/laboratory physician |