Introduction

With Medicare’s adoption of HPV test code 87626 starting January 1, 2025, laboratories and healthcare providers must understand the differences between this new code and existing ones like 87624 and 87625. This update has significant implications for billing, coding compliance, and insurance reimbursement.

This blog post breaks down what makes 87626 different, its clinical relevance, and how labs should prepare for these coding changes.

What is CPT Code 87626?

CPT Code 87626 is a new Medicare-approved test for high-risk HPV (Human Papillomavirus) that allows for:

• Separately reported high-risk HPV types (e.g., 16, 18, 31, 45, 51, 52).
• A pooled high-risk HPV result, which means a combined result indicating the presence or absence of high-risk types.
• More precise diagnostic capabilities compared to the older pooled result approach.

Medicare Fee Schedule: $70.2
Effective Date: January 1, 2025

Do Not Report 87626 in Conjunction With:

• 87624 ($35.09) – Pooled high-risk HPV test.
• 87625 ($40.55) – Individually reported high-risk HPV types 16 and 18, including type 45 if performed.

Understanding the Differences: 87626 vs. 87624 vs. 87625

Why This Matters:
The ability to separately report high-risk genotypes is essential for risk stratification in cervical cancer screening. For example, if HPV 31 is detected, it indicates a higher risk of cervical precancer than HPV 18, helping guide clinical decisions.

Clinical & Billing Considerations

Diagnosis Codes Linked to 87626

Common ICD-10 diagnosis codes that qualify for 87626 include:

• Z00.00, Z00.01 – General health check-ups
• Z01.411, Z01.419 – Cervical cancer screenings
• Z11.51, Z12.4 – HPV screenings

Medicare & Commercial Payor Policies

While Medicare recognizes 87626 starting in 2025, not all commercial insurance payors have updated their policies yet. Laboratories should:

• Review payor guidelines before billing.
• Use appropriate modifiers to ensure full payment with no deductible.
• Consider a payor policy protection plan (like LRN) to stay compliant and maximize reimbursement.

How Laboratories Should Prepare

1️⃣ Update Billing & Coding Procedures – Ensure billing teams are trained on the differences between 87626, 87624, and 87625.
2️⃣ Communicate with Payors – Verify whether commercial payors recognize 87626 and what reimbursement rates apply.
3️⃣ Educate Providers & Clinicians – Inform physicians about the added clinical value of 87626 for cervical cancer screening.
4️⃣ Leverage Payor Policy Protection Plans – If your lab partners with LRN, ensure updated panels reflect the latest payor policies.

Conclusion

The introduction of CPT code 87626 in 2025 represents a major advancement in HPV testing, offering greater diagnostic accuracy compared to older pooled-result tests. Labs must act now to update billing protocols, educate providers, and ensure reimbursement compliance.

Next Steps for Your Lab:

• Train your billing staff on 87626 compliance.
• Confirm commercial insurance acceptance of the new code.
• Stay ahead of reimbursement trends by utilizing payor policy protection plans.

💡 Need expert guidance on laboratory billing and coding updates? Contact LRN today to ensure your lab is prepared for HPV 87626 billing in 2025!