How much does Medicare pay for CPT 86256?

Medicare allowed an average of $12.40 per service and paid $11.90 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $73.87, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 86256?

Measurement of antibody to noninfectious agent. It was billed 18,379 times to 13,511 Medicare beneficiaries by 127 providers in 2024.

Does 86256 pay differently in an office than a hospital?

Yes. The allowed amount averaged $11.85 in an office setting and $17.74 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 86256 most?

Clinical Laboratory, with 16,419 services from 94 clinicians. Next are Pathology, Allergy/ Immunology, Rheumatology.

CPT 86256

Measurement of antibody to noninfectious agent

$12.40Medicare-allowed amount per service, averaged across 18,379 services

Providers submitted

$73.87

Asking price, not received

Medicare allowed

$12.40

The fee schedule figure

Medicare paid

$11.90

Balance is patient coinsurance

Providers submitted an average of $73.87 for this code and Medicare allowed $12.40 — 6.0× 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 $11.90 (96%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $11.85
Hospital / facility: $17.74

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 16,645 services were billed in an office setting and 1,734 in a facility.

Services: 18,379
Beneficiaries: 13,511
Providers billing it: 127
Total allowed: $227,900

What Medicare pays for CPT 86256

Across 18,379 services billed by 127 providers to 13,511 beneficiaries, Medicare allowed an average of $12.40 per service. That is 1.4 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 86256

Specialty	Services	Beneficiaries	Avg allowed	Providers
Clinical Laboratory	16,419	11,753	$11.83	94
Pathology	1,241	1,063	$16.83	28
Allergy/ Immunology	663	651	$18.30	2
Rheumatology	56	44	$11.81	3

86256 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
New York	5,516	$11.81	$11.81	8
California	2,205	$12.35	$11.86	14
New Jersey	1,570	$12.02	$11.87	7
Florida	1,192	$11.94	$11.86	7
Texas	1,160	$12.44	$11.96	10
Massachusetts	1,139	$17.19	$11.96	8
Utah	554	$11.84	$11.82	3
Illinois	521	$11.80	$11.81	3
Tennessee	377	$11.68	$11.78	2
Oklahoma	328	$11.73	$11.81	3
Oregon	287	$11.77	$11.81	2
Ohio	271	$11.77	$11.81	4
Arizona	269	$11.77	$11.81	3
Iowa	261	$15.97	$13.17	5
Colorado	246	$15.99	$12.06	6
Georgia	245	$11.81	$11.81	1
North Carolina	233	$12.07	$11.90	3
Maryland	221	$11.52	$11.81	3
Pennsylvania	208	$11.81	$11.81	2
Puerto Rico	195	$11.34	$11.81	3
New Mexico	167	$11.68	$11.81	1
Wisconsin	163	$11.75	$11.81	4
Kansas	147	$11.81	$11.81	2
Kentucky	134	$11.73	$11.81	2
Rhode Island	124	$11.81	$11.81	1
Michigan	120	$13.74	$12.43	5
Minnesota	111	$11.75	$11.81	2
Nevada	102	$10.77	$11.81	2
Missouri	59	$11.81	$11.81	2
Virginia	59	$11.81	$11.81	1
Arkansas	53	$16.23	$11.87	1
Indiana	31	$11.81	$11.81	1
Maine	27	$11.81	$11.81	1
New Hampshire	27	$17.25	$11.03	1
Mississippi	21	$11.81	$11.81	1
Connecticut	13	$11.81	$11.81	1
Alabama	12	$11.81	$11.81	1
Washington	11	$10.74	$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
86255Screening test for antibody to noninfectious agent$12.39
86231Detection of endomysial antibody (ema)$11.84
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.