Initial antibody staining and interpretation of patient tissue specimen

Description

This code describes the process of applying a single antibody stain to slides prepared from a patient specimen, such as tumor tissue. A qualified pathologist then interprets these stained slides to provide a pathologic diagnosis, aiding in the assessment of disease presence and characteristics.

Medicare Provider Reimbursement (PFS)

Modifier

Facility Setting

Procedure PriceN/A

Limiting ChargeN/A

Patient Coinsurance (20%)N/A

This modifier is not billable under PFS in facility setting. This procedure may be billable under a different modifier (e.g. 26).

Non-Facility Setting

Procedure Price$109.01

Limiting Charge$119.09

Patient Coinsurance (20%)$21.80

RVU Calculation Breakdown

Work RVU

0.70

Practice Expense RVU

2.65

Malpractice RVU

0.02

Total RVU

3.37

0.70 + 2.65 + 0.02 = 3.37

3.37 RVUs×$32.3465 Conversion Factor

$109.01

Medicare Patient Copayment

After meeting the annual Medicare deductible ($1676 per benefit period up to 60 days for inpatient stays under Part A and $257 for outpatient care under Part B in 2026), Medicare patients are typically responsible for 20% of the Medicare-approved amount as coinsurance. The amounts shown are estimates and may vary based on the patient's specific coverage and whether they have supplemental insurance.

Medicare Hospital Outpatient Reimbursement (OPPS)

OPPS Payment Rate

$171.36

Calculation:

x=$171.36

Patient Copayment / Coinsurance

$34.28

Calculation breakdown:

Minimum (20% of rate)$34.28

Sources

We make no claims to ownership of the coding systems referenced on this platform. Codes and descriptions are produced from claims and chargemaster data available through the CMS-9915-F Transparency in Coverage Final Rule and via state or federal datasets. This service is provided solely as a reference to encourage use of these codes in our chargemaster review and automated billing tools, so that healthcare professionals can understand and correctly report these codes in their claims.

Federal and State Datasets

List of CPT/HCPCS Codes, Centers for Medicare & Medicaid Services (CMS)
I/OCE Quarterly Release Files, Centers for Medicare & Medicaid Services (CMS)
Physician Fee Schedule Relative Value Files, Centers for Medicare & Medicaid Services (CMS)
OPPS Addendum B, Centers for Medicare & Medicaid Services (CMS)
ASC Payment Addenda, Centers for Medicare & Medicaid Services (CMS)