Summary & Overview
CPT 87536: HIV-1 RNA (Viral Load) Quantitative Test
CPT code 87536 represents a quantitative molecular assay that measures HIV‑1 RNA (viral load) in a patient specimen. Viral load testing is a cornerstone of HIV care and public health surveillance, guiding clinical management, monitoring antiretroviral therapy effectiveness, and informing transmission risk. Nationally, access to timely and accurate HIV‑1 RNA testing affects patient outcomes and programmatic efforts to control HIV.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication outlines payer coverage patterns, typical sites of service for testing, and clinical context relevant to ordering and interpreting viral load results.
Readers will learn the clinical purpose of CPT code 87536, the common settings where the test is performed, and the typical service type classification. The report also summarizes payer considerations, common billing modifiers (listed separately), and available benchmark information. Data not available in the input is noted where applicable. This summary serves clinicians, laboratory managers, and billing professionals seeking a concise reference on the role and billing identity of HIV‑1 RNA quantitative testing under CPT code 87536.
Billing Code Overview
CPT code 87536 describes a laboratory test that measures the amount of HIV‑1 RNA (viral load) in a patient’s specimen. This quantitative molecular assay determines the concentration of HIV‑1 virus present and is used to monitor infection activity and response to antiretroviral therapy.
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Service type: Laboratory infectious disease molecular diagnostic testing
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Typical site of service: Clinical laboratory, hospital laboratory, or outpatient specimen collection site
Clinical & Coding Specifications
Clinical Context
A typical outpatient adult patient with known HIV infection presents for routine monitoring of antiretroviral therapy effectiveness. A nurse or phlebotomist collects a blood specimen (plasma) during a clinic visit or at an ambulatory laboratory; the specimen is processed and sent to a molecular diagnostic laboratory for quantitative measurement of HIV-1 RNA viral load using nucleic acid amplification techniques. Results guide clinical decisions such as assessing virologic suppression, detecting treatment failure, or prompting resistance testing. Typical sites of service include hospital outpatient departments, physician offices, community health centers, and independent clinical laboratories. Prior to testing, the clinician documents indications such as routine monitoring, suspected treatment failure, recent exposure, or acute infection symptoms, and orders the test in the electronic health record. Specimen collection, labeling, transport, laboratory processing, and result reporting follow CLIA and facility protocols.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When reporting only the professional interpretation or supervision portion of a test provided separately from the technical component. |
TC |