How much does Medicare pay for CPT 86255?

Medicare allowed an average of $12.39 per service and paid $11.95 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $171.43, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 86255?

Screening test for antibody to noninfectious agent. It was billed 102,189 times to 67,682 Medicare beneficiaries by 271 providers in 2024.

Does 86255 pay differently in an office than a hospital?

Yes. The allowed amount averaged $11.82 in an office setting and $17.39 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 86255 most?

Clinical Laboratory, with 85,312 services from 134 clinicians. Next are Pathology, Rheumatology, Allergy/ Immunology.

CPT 86255

Screening test for antibody to noninfectious agent

$12.39Medicare-allowed amount per service, averaged across 102,189 services

Providers submitted

$171.43

Asking price, not received

Medicare allowed

$12.39

The fee schedule figure

Medicare paid

$11.95

Balance is patient coinsurance

Providers submitted an average of $171.43 for this code and Medicare allowed $12.39 — 13.8× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $11.95 (96%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $11.82
Hospital / facility: $17.39

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 91,842 services were billed in an office setting and 10,347 in a facility.

Services: 102,189
Beneficiaries: 67,682
Providers billing it: 271
Total allowed: $1,266,122

What Medicare pays for CPT 86255

Across 102,189 services billed by 271 providers to 67,682 beneficiaries, Medicare allowed an average of $12.39 per service. That is 1.5 services per beneficiary, so this is a code patients typically receive more than once. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 86255

Specialty	Services	Beneficiaries	Avg allowed	Providers
Clinical Laboratory	85,312	57,376	$11.80	134
Pathology	10,215	5,264	$17.17	66
Rheumatology	5,515	4,005	$11.75	61
Allergy/ Immunology	755	749	$18.39	2
Physician Assistant	172	115	$11.81	5
Internal Medicine	163	161	$11.65	2
Neurology	57	12	$11.81	1

86255 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
Florida	15,620	$11.84	$11.82	17
Texas	13,125	$13.11	$12.19	30
California	11,127	$12.64	$11.88	20
New Jersey	8,058	$12.07	$11.87	12
New York	7,359	$11.84	$11.82	19
Minnesota	7,185	$11.80	$11.82	6
North Carolina	5,172	$12.39	$11.99	6
Georgia	5,058	$11.80	$11.81	13
Massachusetts	4,553	$14.94	$12.52	11
Kansas	3,185	$11.83	$11.81	4
Maryland	2,961	$11.78	$11.81	30
Illinois	2,692	$12.53	$11.93	11
Arizona	2,150	$11.78	$11.81	4
Tennessee	2,137	$11.25	$11.28	3
Pennsylvania	1,787	$13.15	$12.06	8
Nevada	1,183	$11.07	$11.81	3
Iowa	1,150	$16.27	$13.06	10
Oklahoma	867	$11.79	$11.81	3
Ohio	729	$12.30	$11.92	11
Wisconsin	717	$11.71	$11.81	2
Michigan	689	$14.96	$12.47	7
Utah	566	$11.81	$11.81	3
Hawaii	521	$11.81	$11.81	2
Colorado	452	$14.07	$11.90	7
South Dakota	391	$11.81	$11.81	2
Virginia	390	$11.76	$11.81	3
Kentucky	363	$11.52	$11.81	2
Oregon	333	$11.71	$11.81	2
Alabama	318	$11.80	$11.81	3
Indiana	314	$14.59	$12.34	4
Washington	261	$11.81	$11.81	2
New Hampshire	250	$15.99	$11.86	2
District of Columbia	179	$11.71	$11.81	3
New Mexico	101	$11.71	$11.81	1
Connecticut	91	$11.81	$11.81	1
Arkansas	69	$16.04	$13.04	1
Mississippi	39	$11.71	$11.81	1
Rhode Island	36	$11.81	$11.81	1
Maine	11	$11.81	$11.81	1

Related codes

86235Measurement of antibody for assessment of autoimmune disorder$17.49
86200Measurement of antibody for rheumatoid arthritis assessment$12.64
86225Measurement of dna antibody$13.43
86258Detection of gliadin (deamidated) (dgp) antibody$11.80
86231Detection of endomysial antibody (ema)$11.84
86256Measurement of antibody to noninfectious agent$12.40
86226Measurement of dna antibody$11.78
86294Immunologic analysis for detection of tumor antigen$25.01
86215Measurement of dna antibody$12.96

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.