CPT 87426 Antigen Immunoassay Benchmarks & Policy | OpenPayer

Summary & Overview

CPT 87426: SARS–CoV–2 Antigen Immunoassay, Blood

CPT code 87426 denotes a laboratory immunoassay to qualitatively or semiquantitatively detect SARS–CoV–2 antigens in a patient blood specimen. This code is used for antigen-based testing that identifies active coronavirus infection through detection of viral proteins rather than nucleic acid. Nationally, antigen testing remains an important diagnostic tool for rapid identification of COVID–19 cases in clinical and public health settings.

Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, United Healthcare, and Medicare. The publication outlines payer coverage context, common clinical uses, and how 87426 compares to related SARS–CoV–2 laboratory codes for molecular testing and antibody assays.

Readers will learn the clinical scope of 87426, typical sites of service where the test is performed, and how it fits alongside related diagnostic codes such as nucleic acid detection and antibody testing. The summary provides benchmarks and policy-relevant points to inform billing, coding, and operational decisions for laboratories and clinicians performing SARS–CoV–2 antigen immunoassays. Data not available in the input where applicable will be noted in detailed sections.

AetnaBlue Cross Blue ShieldCigna HealthUnited HealthcareMedicare87426CPTSARS-CoV-2antigen immunoassayCOVID-19 testingclinical laboratorydiagnostic testinginfectious disease

Billing Code Overview

CPT code 87426 describes an immunoassay performed by a laboratory analyst to qualitatively or semiquantitatively detect antigens of severe acute respiratory syndrome coronavirus (SARS–CoV–2) in a patient blood specimen. The procedure identifies viral antigens associated with coronavirus disease 2019 (COVID–19) and is used to determine current infection status based on antigen presence.

Service Type: Clinical laboratory infectious agent antigen detection by immunoassay.

Typical Site of Service: Clinical laboratory or hospital laboratory setting; specimen collection commonly occurs in outpatient clinics, testing centers, or hospital phlebotomy units.

Clinical & Coding Specifications

Clinical Context

A 58-year-old patient presents to a primary care clinic with fever, cough, and shortness of breath. The clinician documents a suspected COVID-19 infection and orders laboratory testing. A phlebotomy technician collects a blood specimen which is routed to the clinical laboratory. A medical laboratory scientist or lab analyst performs an immunoassay to qualitatively or semiquantitatively evaluate the specimen for SARS–CoV–2 antigens, supporting diagnosis of acute infection. Typical workflow: clinician order placed; specimen collection and labeling; transport to Clinical Medical Laboratory; accessioning and processing; immunoassay performed using validated SARS–CoV–2 antigen kit; result validated by laboratorian; final report released to ordering Family Medicine or Internal Medicine provider; electronic health record updated and care plan adjusted (isolation, additional testing such as nucleic acid amplification testing, or treatment) based on results and clinical context. Typical site of service: outpatient clinic laboratory, hospital laboratory, or independent clinical laboratory. Typical patient scenario includes symptomatic patients with ICD-10 codes such as U07.1 (confirmed COVID-19), R05 (cough), screening encounters Z11.52, known exposure Z20.822, or COVID-19 pneumonia J12.82 when antigen testing is used as part of diagnostic evaluation or screening.

Coding Specifications

Modifier	Description	When to Use

CPT 99202: Office Visit for New Patients, Straightforward Decision Making

96372-THERAPEUTIC-PROPHYLACTIC-OR-DIAGNOSTIC-INJECTION-SPECIFY

CPT 96372: Therapeutic, Prophylactic, or Diagnostic Injection Administration

99212-OFFICE-OR-OTHER-OUTPATIENT-VISIT-FOR-THE-EVALUATION-AND

CPT 99212: Office Visit for Established Patients, Straightforward Decision Making

99215-THE-PROVIDER-SEES-AN-ESTABLISHED-PATIENT-FOR-AN-OFFICE

CPT 99215: Office Visit for Established Patients, High Complexity

CPT-10121-DEEP-FOREIGN-BODY-REMOVAL-SOFT-TISSUE

CPT 10121: Removal of Deep Foreign Body from Soft Tissue

73110-RADIOLOGIC-EXAMINATION-WRIST-COMPLETE-MINIMUM-OF-3

CPT 73110: Radiologic Examination of Wrist, Complete (≥3 Views)

12004-SIMPLE-REPAIR-OF-SUPERFICIAL-WOUNDS-OF-SCALP-NECK-AXILLAE

CPT 12004: Simple Repair of Superficial Wounds, 7.6-12.5 cm

99214-OFFICE-OR-OTHER-OUTPATIENT-VISIT-FOR-THE-EVALUATION-AND

CPT 99214: Office Visit for Established Patients, Moderate Complexity

87502-INFECTIOUS-AGENT-DETECTION-BY-NUCLEIC-ACID-DNA-OR-RNA

CPT 87502: Influenza Virus Detection by Multiplex Nucleic Acid Technique

99213-OFFICE-OR-OTHER-OUTPATIENT-VISIT-FOR-THE-EVALUATION-AND

CPT 99213: Office Visit for Established Patients, Low Complexity

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Taxonomy Code	Specialty	Notes
`291U00000X`	Clinical Medical Laboratory	Primary performing setting for laboratory testing and reporting
`207Q00000X`	Family Medicine Physician	Common ordering provider for community-based testing and initial clinical evaluation
`207R00000X`	Internal Medicine Physician	Common ordering provider for adult patients and inpatient/clinic management

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`U07.1`	COVID-19, virus identified	Direct indication for SARS–CoV–2 antigen testing to identify active infection
`Z20.822`	Contact with and (suspected) exposure to COVID-19	Testing indicated for exposed asymptomatic or symptomatic contacts per screening protocols
`J12.82`	Pneumonia due to coronavirus disease 2019	Antigen testing as part of diagnostic evaluation for COVID-19–related pneumonia
`Z11.52`	Encounter for screening for COVID-19	Screening context where antigen testing may be ordered for surveillance or pre-procedure checks
`R05`	Cough	Symptom prompting SARS–CoV–2 testing to evaluate for acute COVID-19 infection

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`87635`	Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2	Molecular NAAT performed when higher sensitivity is needed or to confirm antigen results
`87811`	Infectious agent antigen detection by immunoassay with direct optical observation; SARS-CoV-2	Alternative antigen detection methodology; may represent point-of-care or lab-based antigen testing
`86769`	Antibody detection, SARS-CoV-2	Serologic testing for prior infection or immune response; not used for acute antigen detection but often ordered in different clinical contexts
`86328`	Immunoassay for infectious agent antibody, qualitative or semiquantitative; SARS-CoV-2	Another serologic immunoassay code for antibody testing; complementary to antigen testing in clinical workflows

`26`	Professional component	When billing only the professional interpretation component if separated from technical component
`91`	Repeat clinical diagnostic laboratory test	When the same SARS–CoV–2 antigen test is repeated on the same day for confirmation per clinical policy
`90`	Reference (outside) laboratory	When testing performed by an outside reference laboratory
`95`	Synchronous telemedicine service rendered via real-time interactive audio and video	When result review and patient counseling occur via telemedicine and payer requires modifier for telehealth services tied to lab-related visit
`TC`	Technical component	When billing only the technical component of the laboratory test
`52`	Reduced services	When testing is partially performed or limited relative to full procedure
`53`	Discontinued procedure	When testing procedure started but discontinued for patient safety or specimen unsuitability
`59`	Distinct procedural service	When bundling edits require distinct reporting because a separate, unrelated laboratory service was provided
`90`	Reference (outside) laboratory	When the performing lab sends testing to a third-party reference lab (listed to indicate common use)
`QW`	CLIA waived test	When the performed immunoassay is a CLIA-waived SARS–CoV–2 antigen test

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