CPT code 87904: HIV-1 phenotype, each additional drug2026 Medicare lab fee · Clinical Laboratory Fee Schedule
Add-on HIV-1 phenotypic drug-resistance analysis reported for each additional drug tested with the primary tissue-culture phenotype service.
Medicare pays $26.07 for 87904 under the 2026 Clinical Laboratory Fee Schedule: one national amount, the same in every state and setting.
Medicare lab fee · CLFS 2026 Q4
National CLFS amount
$26.07
In effect since Jan 1, 2026. The same amount in every state, payment locality and setting.
- Geographic adjustment
- None
- Office vs facility
- Same
- Since 2020
- Unchanged
- CMS updates
- Quarterly
Medicare pays the lesser of the lab’s charge and this amount. Patients usually owe no Part B deductible or coinsurance for covered clinical lab tests.
On this page 8 sections
What 87904 covers
This add-on represents phenotypic HIV-1 drug-resistance analysis for each additional drug tested beyond the primary phenotype analysis. The laboratory evaluates viral response using nucleic-acid analysis with tissue-culture drug-resistance testing; the result is phenotypic rather than genotypic. Infectious-disease clinicians may use HIV-1 resistance results when selecting or adjusting antiretroviral therapy. Specialized laboratories perform and report the assay for ordering clinicians.
Report 87904 with the primary HIV-1 phenotype service, 87903, and count each additional drug tested as a separate unit. It is an add-on, not a stand-alone HIV test or a second code for the same primary drug analysis. Medicare pays it under the CLFS at one national rate across states and localities, without geographic or office-versus-facility adjustment. The 2026 national CLFS amount is $26.07, unchanged since 2020. The service is paid through the CLFS rather than the physician fee schedule.
This summary was written with AI assistance from CMS Clinical Laboratory Fee Schedule data. Amounts on this page come directly from CMS files.
How Medicare pays 87904
Clinical lab tests aren’t priced like physician services. They’re paid from their own fee schedule, with its own rules. See the whole lab fee schedule.
One national amount
CMS sets a single Clinical Laboratory Fee Schedule amount for 87904. There’s no geographic (GPCI) adjustment, so it pays the same in every state and payment locality.
No office or facility rate
Lab tests aren’t built from relative value units, so there’s no office and facility split: the place of service doesn’t change the CLFS amount.
Updated every quarter
CMS republishes the CLFS each quarter. New tests, often proprietary laboratory analyses (PLA codes), join during the year; existing amounts are updated each January.
Excluded from the physician fee schedule
The physician fee schedule lists 87904 with status X (excluded by statute), so the test itself is paid only from the CLFS.
87904 on the lab fee schedule since 2020
87904 · CLFS 2026 Q4 (current)
$26.07
Unchanged since Jan 1, 2020
27 quarterly CLFS releases on file, first CLFS 2020 Q1. A code missing from a quarter wasn’t on that release.
87904 compared with similar tests
- 87903HIV resistancePhenotype, first 10 drugs$488.66
- 87903 reports the primary HIV-1 phenotypic drug-resistance service. Use 87904 for each additional drug tested with that service.
- 87901HIV genotypeRT and protease regions$257.45
- 87901 analyzes HIV-1 genotype in the reverse transcriptase gene; 87904 covers additional drugs tested through phenotypic analysis.
- 87906HIV genotypeOther genomic region$128.73
- 87906 is HIV-1 genotypic analysis. 87904 is an add-on for additional drugs tested in HIV-1 phenotypic analysis.
87904 billing questions
When should 87904 be reported instead of 87903?
Report 87903 for the primary HIV-1 phenotypic drug-resistance analysis. Add 87904 for each additional drug tested as part of that analysis.
Can 87904 be reported by itself?
No. It is an add-on to the primary HIV-1 phenotype service, 87903.
How many units should be reported?
Report one unit for each additional drug tested under this add-on code.
How does Medicare pay 87904?
Medicare pays the test through the CLFS at one national amount, with no geographic or office-versus-facility adjustment.
Is 87904 paid under the physician fee schedule?
No. Medicare pays this test only through the CLFS.
Where this amount comes from
FeeBase reads lab amounts directly from the CMS Clinical Laboratory Fee Schedule file for the quarter: one row per code, with its payment indicator and national amount. Contractor-priced tests are labeled, never given a made-up amount. Amounts are Medicare payment limits, not a patient’s bill or a commercial rate.
CMS CLFS 2026 Q4 · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file line behind this amount
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