CPT code 87522 – Hepatitis C viral load test

Key takeaways

CPT code 87522 bills a quantitative hepatitis C RNA test, reported as a viral load in IU/mL.

A qualitative detected or not detected result is 87521, and a direct probe test without amplification is 87520.

B18.2 supports most treatment and monitoring claims, while Z11.59 fits screening orders only.

Medicare pays 87522 from the Clinical Laboratory Fee Schedule, and MolDX MACs may apply additional evidence criteria.

Only the CLIA-certified lab that ran the assay bills 87522, under its own NPI and CLIA number.

CPT code 87522 is the hepatitis C viral load test

CPT code 87522 reports a quantitative hepatitis C virus (HCV) RNA test. The American Medical Association descriptor reads: Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription, when performed.

The word that matters is “quantification.” The lab returns a viral load in international units per milliliter (IU/mL). That number is what sets 87522 apart from the other two codes in its family.

All three codes share one descriptor stem and split on technique and output. Picking the wrong one is the most common coding error here, so this is how they line up.

87522 sits in the microbiology section of CPT’s pathology and laboratory chapter. Gastroenterology, infectious disease and hepatology practices see it most. So does any lab running RT-PCR, transcription-mediated amplification (TMA) or branched DNA (bDNA) assays for HCV.

Four reasons a provider orders an HCV viral load

The viral load drives four different clinical decisions. Each one is a separate medical justification, and the order has to say which applies.

• Confirming active infection. An HCV antibody test (CPT 86803 or 86804) shows exposure, not active infection. After a positive antibody, 87522 confirms viremia and sets the baseline viral load.
• Treatment baseline. Direct-acting antiviral (DAA) therapy starts from a pre-treatment viral load. Note the planned DAA start date in the chart.
• On-treatment monitoring. Some protocols and payers call for retesting during therapy. Frequency edits apply, so record the protocol and treatment week on every order.
• Confirming cure. A test 12 weeks after treatment ends (SVR12) confirms sustained virologic response. Each post-treatment draw needs its own documented indication.

Payers look for that scenario in the chart note. An order that reads only “HCV RNA PCR,” with no treatment phase or diagnosis, is the fastest route to a medical necessity denial.

87522, 87521 or 87520: Let the lab report decide

The classic mistake is billing 87521 for a quantitative assay. 87521 reports presence or absence only. If the lab report shows a numeric IU/mL result, the code is 87522, whichever method the lab used to get there.

Two questions on the report settle the choice, as the diagram below shows.

• The report reads “HCV RNA, Quantitative” or “HCV Viral Load” and shows a number. Bill 87522.
• It reads “HCV RNA, Qualitative” with detected or not detected. Bill 87521 when the RNA was amplified.
• The lab used a direct probe with no amplification. Bill 87520. Few modern reference labs still run this method.

When the report is unclear, ask the performing lab for its assay description. That document, not the wording on the order, decides the code.

Medical necessity documentation that survives review

Payer policies, Local Coverage Determinations (LCDs) and their billing articles set medical necessity for 87522. In MolDX jurisdictions, the Medicare Administrative Contractor (MAC) may also apply additional evidence criteria. A claim that holds up under review usually carries five elements.

• A confirmed or suspected HCV diagnosis. The note references a positive antibody result or a documented HCV diagnosis, such as B18.2.
• The indication for this specific test. State whether it is confirmation, treatment baseline, monitoring at a named treatment week or SVR. “Monitor HCV” on its own won’t pass.
• An identified, authenticated order. CMS requires the ordering provider to be identified, and the order must be signed or otherwise authenticated.
• A reason for any repeat test. Many LCDs set frequency limits. If the patient had 87522 recently, document why another one is clinically needed now.
• A CLIA certificate on file. The performing lab needs a CLIA certificate that covers the test’s complexity.

Check the applicable LCD before you submit. MolDX MACs use the same CPT code but may apply additional evidence criteria that non-MolDX MACs don’t.

ICD-10 codes that support CPT code 87522

A diagnosis code the payer doesn’t accept for 87522 is one of the most common reasons this code is denied. Confirm each code is current with the CDC/NCHS ICD-10-CM lookup tool before each claim cycle. These are the pairings that come up most.

B18.2 is the primary diagnosis on most 87522 claims. Z11.59 belongs on a screening order and nowhere else. Confirming a positive antibody is diagnostic work, so code the documented finding, such as R76.8, or B18.2 once HCV is established.

On a genuine screening claim, some payers also want a secondary code for the risk factor behind the screen. Z72.89 (other problems related to lifestyle) or a substance use history code are typical choices.

How an 87522 claim moves from draw to payment

Seven hand-offs sit between the order and the money. Knowing where each one can fail tells you where to look when a claim stalls.

1. Order. The ordering provider documents the indication and diagnosis, and the order names a quantitative test.
2. Draw and send. The practice draws the specimen and sends it out, or runs it in its own certified lab.
3. Result. The lab runs the assay and reports a viral load in IU/mL.
4. Coding. The performing lab assigns 87522 and lists the ordering provider in the referring provider fields.
5. Submission. The claim goes out on a CMS-1500 or its electronic form, the 837P, with the lab’s CLIA number. A clearinghouse scrubs it for format and code edits first.
6. Adjudication. The payer checks the diagnosis against its policy, applies frequency edits and prices the line.
7. Remittance. An electronic remittance advice (ERA) shows the payment or the denial reason code.

Steps one and four are the weak points. A vague indication fails at adjudication, while a wrong code or CLIA number bounces at the clearinghouse.

Medicare pays 87522 from the lab fee schedule

CMS pays CPT 87522 under the Clinical Laboratory Fee Schedule (CLFS), not the Physician Fee Schedule. Physician office labs and reference labs bill it on a CMS-1500 or 837P. The amount comes from the annual CLFS update, not from relative value units.

CLFS rates change every calendar year, so look up the current figure in the Clinical Laboratory Fee Schedule files on the CMS site. Historically, 87522 has paid more than 87521, reflecting the extra work of quantifying the virus.

Private payer rates follow each contract. Reference labs with rates negotiated above the CLFS collect more per test, and in-network physician office labs are held to their contracted rates.

Pabau, the practice management and billing platform we build, connects to US payers through Claim.MD. Your team can run an eligibility check before the draw and receive the ERA after adjudication.

Prior authorization for 87522 depends on the payer

Prior authorization (PA) for 87522 varies by payer and plan. Medicare fee-for-service generally doesn’t require PA for lab tests paid under the CLFS. Medicare Advantage plans often set their own PA rules, separate from traditional Medicare.

Commercial payers and Medicaid managed care plans vary the most. Many require PA for repeat viral load testing within a plan year. Run insurance eligibility verification before every draw, not just at diagnosis, so a PA requirement shows up before the specimen is taken.

When a plan does require PA, the request usually includes:

• The ordering provider’s note with the HCV diagnosis and treatment phase.
• The latest antibody result or prior viral load.
• A reference to the AASLD/IDSA HCV guidance, which payers widely accept.

Send the request at least five business days before the planned draw.

Can CPT 87522 be billed with 87902 genotyping?

Yes, in most cases. CPT 87902 identifies the HCV genotype (1a, 1b, 2, 3 and so on), which guides the choice of DAA regimen. Ordering it with 87522 at treatment start is standard. The viral load sets the baseline, and the genotype picks the regimen.

We know of no National Correct Coding Initiative (NCCI) edit that bundles 87902 with 87522. Both can generally be billed on the same date of service when both assays were run. The note should still give the reason for each, so a reviewer sees two distinct purposes.

NCCI edits update quarterly, so check the current tables before submitting any code pair. The AAPC code lookup shows current edits beside each descriptor.

Before you submit an 87522 claim: A quick checklist

• The lab report shows a numeric IU/mL result.
• The order names the indication: confirmation, baseline, a treatment week or SVR.
• The primary diagnosis fits that indication, and Z11.59 appears only on a screening order.
• A repeat test inside the payer’s frequency window has a documented reason.
• The CLIA number belongs to the lab that ran the test.
• The ordering provider’s NPI is in the referring field, and the billing NPI is the performing lab’s.
• Eligibility and any PA were checked for this draw, not only the first one.
• If 87902 ran the same day, the note explains why both tests were needed.

Common 87522 denials, and the fix for each

Denials for 87522 tend to cluster around five causes. The denial management workflows you use for other lab claims apply here, with a few twists specific to this code.

To appeal a denied 87522 claim, send the lab report showing the quantitative result and the note with the indication. Add the AASLD/IDSA guidance section that supports the draw frequency, and cite the payer’s LCD by number.

Our guide to medical billing denial codes explains the remittance codes you’ll meet. On 87522, CARC 50 (not deemed medically necessary) and CARC 97 (payment included in another service) come up most often.

Who bills 87522 depends on who ran the test

Only the entity that performed the assay bills 87522. An ordering provider bills it only when their practice runs a CLIA-certified physician office lab (POL) approved for the test’s complexity. When the specimen goes to a reference lab, that lab bills under its own NPI and CLIA number.

• Reference laboratory. Bills 87522 under its own NPI and CLIA number and receives the payment. The ordering provider’s NPI appears in the referring provider fields.
• Physician office lab. May bill 87522 with a CLIA certificate that covers the test. The practice’s NPI and CLIA number go on the claim, and the superbill should capture the CLIA number beside the CPT code.
• Hospital outpatient lab. Bills under the hospital’s CLIA certificate through its outpatient lab billing, not the physician fee schedule.
• FQHC or RHC. Federally Qualified Health Centers and Rural Health Clinics usually send specimens to reference labs. Billing in-house tests needs separate lab enrollment and the right CLIA certificate.

In any setting, clean claim submission for 87522 needs three matching pieces. The CLIA number goes in item 23 of the CMS-1500 or the matching 837P segment. The ordering provider’s NPI goes in the referring field, and the performing lab’s NPI is the billing entity.

How Pabau keeps 87522 claims clean from order to payment

Most 87522 problems start before the claim exists. The order is vague, the eligibility check gets skipped, or the result never makes it back to the chart. Each one turns into an appeal weeks later.

Practices can switch on lab ordering in Pabau. US practices order Quest tests from the patient record, and Quest and Labcorp results import automatically. A results chart on the record shows each viral load against the last, so the treatment story is documented as it happens.

Claims run from the same record. Eligibility checks, CMS-1500 and 837P claims and ERA remittances go through Claim.MD, so your billing team works from the note and result the clinician saw.

Bill HCV viral loads without the rework

Pabau connects to US payers through Claim.MD. Your team checks eligibility before the draw, submits 837P claims and tracks ERA responses from the patient record.

Book a demo

Conclusion

The code itself is rarely what sinks an 87522 claim. It follows the lab report, and the report is clear once someone reads the result line. Claims fail on the paperwork around the number, such as a missing treatment phase or a screening code on a confirmation draw.

So put the effort upstream. Write the indication into every order, check eligibility before each draw rather than once per course, and keep Z11.59 for screening. With claims management software doing the checks, those errors surface before submission instead of in an appeal.

Book a demo to see how Pabau links HCV lab orders, results and claims on one patient record.

Continue your research

Need to understand how clearinghouse submission works for lab claims? Claim.MD clearinghouse guide explains how electronic lab claims route from practice to payer and back.

Getting ERA remittance codes you don’t recognize? Electronic remittance advice explained breaks down ERA file structure and how to read CARC and RARC denial reason codes.

Billing the antibody test that comes before the viral load? CPT code 86803 covers the hepatitis C antibody test and how to bill it.

Ordering a full acute hepatitis workup instead? CPT code 80074 covers the acute hepatitis panel, which includes the HCV antibody.

Looking for a revenue cycle overview that covers lab billing? Revenue cycle management guide covers the full claim lifecycle from patient registration through payment posting.

Frequently asked questions