The 2026 CPT code set introduces significant updates to laboratory and pathology billing, particularly for molecular diagnostics and Proprietary Laboratory Analyses (PLA). Labs must adapt their coding workflows to maintain compliance and optimize reimbursement. Over 300 codes span the 80000-89999 range, plus dozens of new PLA codes address advanced genomic testing.
The American Medical Association released substantial revisions to the lab CPT codes 2026, effective January 1, 2026. In contrast to incremental annual updates, this year’s changes reflect the rapid evolution of molecular diagnostics, infectious disease testing, and precision medicine applications that traditional chemistry and hematology codes couldn’t adequately describe.
In this guide, we’ll walk you through the most commonly used laboratory CPT codes for 2026, providing essential billing tips and practical advice to help you navigate these updates.
Most Common Laboratory CPT Codes 2026
These common lab CPT codes 2026 represent high-volume tests across clinical settings. Each entry includes billing specifications that prevent documentation gaps, causing claim delays.
CPT Code 80048
Basic Metabolic Panel (BMP) is used to assess kidney function, electrolyte balance, and glucose metabolism. The test includes eight analytes: calcium, carbon dioxide, chloride, creatinine, glucose, potassium, sodium, and blood urea nitrogen. It takes 15-30 minutes using automated chemistry analyzers. Billing should not include individual analyte codes (e.g., CPT 82310) when reporting 80048, as NCCI bundling edits prevent separate payment. Denials occur if individual component codes are billed alongside the panel.
CPT Code 85025
Complete Blood Count (CBC) with Automated Differential is used to evaluate red and white blood cells and platelets, crucial for diagnosing infections, anemia, and hematologic disorders. It includes a five-part white blood cell differential. Processing takes 5-10 minutes using hematology analyzers. Don’t bill 85025 if only a CBC without differential is performed; use 85027 instead. Denials often occur due to frequency limitations or if repeat CBCs are billed without a clear clinical need.
CPT Code 87635
Infectious Agent Detection, SARS-CoV-2 (COVID-19), Amplified Probe is used for detecting SARS-CoV-2 RNA via nucleic acid amplification, such as RT-PCR. It is commonly used for screening immunocompromised patients and pre-procedure testing. The test takes 45-90 minutes for RT-PCR platforms or 15-30 minutes for rapid molecular systems. Don’t bill 87635 with multiplex panels detecting multiple viruses; use panel codes instead. Denials may occur if this code is billed with other individual COVID-19 detection tests.
CPT Code 81002
Urinalysis is used to check for urinary tract infections, kidney conditions, and diabetes through chemical analysis of urine. It takes 15-30 minutes using dipstick methods. Billing should only include the chemical tests, excluding microscopic analysis. Common denials occur if microscopic tests are billed separately.
CPT Code 80050
Organ or Disease-Oriented Panels is used for general health or disease-specific screenings, assessing organ function, and disease risk. Processing takes 45-60 minutes for multiple analytes. Bill only when the full panel is ordered; partial tests should be billed separately. Denials occur when only a subset of tests is performed.
CPT Code 87880
Infectious Agent Antigen Detection detects Group A Streptococcus antigens in throat swabs, commonly used for diagnosing strep throat. The test takes 15-20 minutes using rapid antigen detection. Bill only for antigen detection; PCR testing requires a different code. Denials occur if PCR codes are billed with antigen detection.
CPT Code 86000
Febrile Agglutinins Detection identifies febrile agglutinins for diseases like Q fever and Rocky Mountain spotted fever. Processing time is 30-45 minutes, depending on the number of antigens. Bill each antigen tested separately. Denials occur if multiple pathogen tests are billed under a single code.
CPT Code 80157
Free Carbamazepine Detection measures the free concentration of carbamazepine in blood to prevent toxicity. Testing takes 30-45 minutes. Only carbamazepine analysis is included, and related tests should be billed separately. Denials may occur if tests for protein-bound carbamazepine are billed incorrectly.
CPT Code 81419
The Neurological Seizure Disorder Diagnostic Procedure is used for genomic sequencing to diagnose seizure disorders like epilepsy. It takes 1-2 hours for sequencing. Bill only for the complete multi-gene panel, not individual gene tests. Denials occur if individual gene tests are billed alongside the panel.
CPT Code 86901
Blood Type Detection determines a patient’s blood type within the Rh blood group system, crucial for transfusions. It takes 15-20 minutes using blood serum analysis. Only bill for blood typing; other related tests should be billed separately. Denials may occur if additional tests are bundled with blood typing.
Billing Compliance for Proprietary Laboratory Analyses (PLA) codes
Exact Test Verification
Confirm the laboratory performing analysis is the specific manufacturer/developer listed in the PLA code descriptor. Sending specimens to different laboratories performing “equivalent” testing requires different codes.
Prior Authorization Requirements
Most commercial payers and Medicare Administrative Contractors require prior authorization for PLA codes, given the high cost and evolving evidence base. Authorization requests need detailed clinical documentation explaining how test results will alter management.
Medical Necessity Documentation
Generic diagnoses often don’t support PLA code medical necessity. Documentation should explain why this specific proprietary test provides information that standard testing can’t offer and how results will guide treatment decisions.
Coverage Limitations
Many PLA codes lack established coverage policies. Before ordering, verify whether the patient’s specific payer covers the test. Some payers reimburse under individual consideration, while others categorically exclude coverage pending additional evidence.
LCD and NCD Compliance
Check whether local coverage determinations or national coverage determinations exist for the specific PLA code. These policies define covered indications, frequency limitations, and required documentation that must be present before testing.
Laboratory Billing Guidelines 2026
Accurate lab billing guidelines 2026 implementation prevents the coding errors that delay reimbursement and trigger audits. These evidence-based practices align with CMS requirements and commercial payer policies.
Use Specific CPT Codes, Not Method Codes
Select codes based on what was measured or detected, not the methodology used to perform testing. For example when quantifying glucose, use 82947 (glucose, blood quantitative) regardless of whether the measurement used the enzymatic method, hexokinase, or glucose oxidase. The analyte measured determines code selection, not the instrumental technique.
When the analyte has multiple codes based on methodology (e.g., qualitative vs. quantitative, screening vs. confirmation), the method does affect code selection. Review code descriptors carefully to identify when methodology distinction matters.
Apply Panel Codes When All Components Are Performed
When a provider orders all tests included in an organ or disease-oriented panel (80047-80081), bill only the panel code. Panel codes bundle multiple analytes into a single reimbursement, often paying less than the components would individually, but NCCI edits prevent separate billing.
If even one panel component wasn’t ordered or performed, you cannot bill the panel code. Bill individual component codes instead.
The provider orders a “metabolic panel” without specifying basic or comprehensive. The laboratory performs a comprehensive panel (80053), but provider documentation only supports basic panel medical necessity. Bill 80048 (BMP) can only be billed for what was medically necessary and documented, even if more testing was actually performed.
Verify Medical Necessity Before Testing
The ordering provider determines medical necessity, but laboratories share responsibility for billing only medically necessary services. When test orders appear inconsistent with the diagnosis or exceed frequency limitations, query the ordering provider before performing testing.
Advance Beneficiary Notice (ABN): When Medicare medical necessity appears questionable, provide ABN to the patient before testing, explaining Medicare may not cover the test, and the patient may be responsible for payment. Document ABN signatures and maintain files per CMS requirements (minimum 10 years).
Frequency Limitations: Many laboratory tests have coverage frequency limits. Examples:
- Lipid panels: Every 5 years for asymptomatic screening
- HbA1c: Every 3-6 months, depending on diabetes stability
- PSA: Annually for screening
- Vitamin D: Not covered for screening in asymptomatic patients without risk factors
Testing exceeding these frequencies requires documentation of medical necessity supporting more frequent monitoring.
Modifier Requirements for Laboratory Billing
Laboratory-specific modifiers communicate additional information affecting payment or medical necessity.
- Modifier 59 (Distinct Procedural Service) indicates that procedures normally bundled together are separately billable due to distinct clinical circumstances. For example, when two separate tests are done on the patient’s same day, both of which have documented medical necessity, they may be billed separately as they are both distinct services.
- Modifier 91 (Repeat Clinical Diagnostic Laboratory Test) is used for laboratory tests repeated on the same day to obtain subsequent values for the same patient, like serial testing for acute coronary syndrome, making it more appropriate than Modifier 59 for this purpose.
- Modifier 90 (Reference Laboratory) is used when a test is sent to an outside reference laboratory, but the billing laboratory, such as a physician’s office or hospital, is eligible to bill the service directly to the payer.
- Modifier 26 (Professional Component) applies when a procedure includes both a technical and professional component, such as when a physician’s interpretation is billed separately from the technical performance, like in bone marrow pathology.
- Modifier QW (CLIA-Waived Test) is an additional modifier some payers require when billing for CLIA-waived tests, also known as point-of-care tests. However, Medicare does not require this modifier; therefore, it is important to confirm individual payer requirements.
Use Proper ICD-10 Code Pairing
ICD-10 codes must support medical necessity for ordered tests. The diagnosis justifying testing should reflect the clinical reason for ordering, not necessarily the test result.
Use Most Specific Diagnosis Available: “Anemia, unspecified” (D64.9) is less supportable than “Iron deficiency anemia” (D50.9) when ordering iron studies. More specific diagnoses demonstrate clearer medical necessity.
Match Diagnosis to Test Ordered: When ordering a lipid panel, cardiovascular-related diagnoses (hyperlipidemia, atherosclerosis, diabetes) support medical necessity. Using an unrelated diagnosis like “headache” creates a medical necessity question, even if the patient coincidentally has both conditions.
Avoid Screening Codes When Symptoms Present: Screening codes (Z13.x series) indicate asymptomatic evaluation. When a patient has symptoms or a known disease, use diagnostic codes instead. Example: Patients with known diabetes getting HbA1c should have diabetes code (E11.x), not screening code.
Sign/Symptom Codes as Last Resort: When a definitive diagnosis is unavailable, signs and symptoms codes (R00-R99 series) are appropriate. However, if testing a previously confirmed diagnosis, use that diagnosis code rather than symptoms. Example: Patient with confirmed hypothyroidism on levothyroxine getting TSH monitoring should use hypothyroidism code (E03.9), not “fatigue” (R53.83).
Conclusion
The 2026 lab CPT codes highlight the shift toward molecular diagnostics, genomic medicine, and precision therapeutics, areas where traditional codes couldn’t fully capture the evolving landscape. With over 50 new codes and numerous revisions, labs must adjust their coding practices accordingly.
Accurate coding involves understanding why the test was ordered, how results were analyzed, and whether specific methods or approaches impact the code selection.
For labs navigating these changes, Nexus io offers specialized laboratory billing services to ensure your coding is accurate, compliant, and optimized for reimbursement. Let us help you stay ahead of the curve in this evolving field.
