CPT 85097Laboratory

Bone marrow interpretation

CPT code 85097 covers the professional interpretation of a bone marrow sample by a physician or qualified pathologist. This is the analytical work of examining the bone marrow cells under a microscope and providing a diagnostic report, separate from the actual procedure of collecting the sample.

Showing rates for

National Average

Base Medicare rate

$67.28

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.94

PE RVU (NF)

1.1

MP RVU

0.04

Total RVU

2.08

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Bill 85097 separately from bone marrow aspiration/biopsy codes (38220, 38222) as it represents professional interpretation, not the procedure
Impact: Recovers additional $67.28 per interpretation that is often missed when only procedure codes are billed
Ensure documentation includes formal written report with morphologic description, differential diagnosis, and diagnostic conclusion signed by interpreting pathologist
Impact: Prevents denials for lack of medical necessity or documentation; reduces audit risk by 70-80%
Use modifier 26 when interpretation is performed by independent pathologist while hospital bills technical component
Impact: Ensures correct payment split; prevents overpayment recovery audits averaging $1,200-$2,500 per incident
Link to appropriate ICD-10 codes for anemia, thrombocytopenia, suspected leukemia, or staging codes to support medical necessity
Impact: Reduces denial rate by 45-60%; diagnosis codes D60-D64, D69, C91-C95 have highest approval rates
Submit with date of interpretation, not date of specimen collection, when there is a delay between procedures
Impact: Prevents timely filing denials and clarifies when professional service was actually rendered
Do not bill 85097 with bone marrow smear examination codes (85060) as this is bundled into the interpretation
Impact: Avoids unbundling denials and CCI edits that result in claim rejection or payment recoupment

Common denials

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 85097 in 2025?

The 2025 Medicare national average reimbursement for CPT 85097 is $67.28 for non-facility settings and $45.29 for facility settings, based on the CMS Physician Fee Schedule with a conversion factor of 32.3465.

Can CPT 85097 be billed with bone marrow aspiration code 38220?

Yes, CPT 85097 can and should be billed separately from 38220 (bone marrow aspiration). Code 38220 represents the procedural component of obtaining the specimen, while 85097 represents the professional interpretation and diagnostic analysis by a pathologist or hematologist.

Who can bill CPT code 85097 for bone marrow interpretation?

CPT 85097 must be billed by or under the supervision of a qualified physician, typically a pathologist with hematopathology training, clinical pathologist, or hematologist/oncologist with appropriate credentials to interpret bone marrow specimens and generate diagnostic reports.

Do I need modifier 26 when billing 85097?

Use modifier 26 only when billing the professional component separately because the technical component is being billed by a facility. If you are billing the complete service (both professional interpretation and technical resources), bill 85097 without a modifier.

What RVU value is assigned to CPT 85097?

CPT 85097 has a total RVU of 2.08 for 2025, consisting of 0.94 work RVU, 1.1 non-facility practice expense RVU (0.42 facility), and 0.04 malpractice RVU according to the CMS Physician Fee Schedule.

What documentation is required to support billing CPT 85097?

Required documentation includes a formal signed pathology report with microscopic description of bone marrow morphology, cellularity assessment, evaluation of all cell lineages, myeloid-to-erythroid ratio, identification of abnormalities, and diagnostic interpretation with clinical correlation by a qualified pathologist.

What are common denial reasons for CPT 85097?

Common denials include: bundling with procedure codes (38220/38222), lack of signed interpretation report, insufficient medical necessity documentation, incorrect modifier use with TC/26 splits, and duplicate billing with other pathology interpretation codes on the same date.