What Pathology and Lab teams should benchmark
Pathology and Lab IDR outcomes are shaped by code mix. The same payer can look fair in one lane and misaligned in another. Start with the codes that dominate your disputed claims, then compare state and payer behavior.
The purpose of this page is to help a specialty leader or RCM team decide where the federal IDR data supports a closer claim-level review.
Top Pathology and Lab service codes
| Code | Service | Disputes | Provider win rate | Median award | Median award dollars |
|---|---|---|---|---|---|
| 85025 | Complete blood count (CBC) with automated differential | 111,383 | 81.2% | 4.5x | $268 |
| 80053 | Comprehensive metabolic panel (14 blood chemistry tests) | 89,943 | 80.9% | 6.7x | $582 |
| 81003 | Urinalysis, automated, without microscopy | 56,251 | 79.2% | 7.4x | $194 |
| 84484 | Troponin blood test (cardiac injury marker), quantitative | 37,869 | 81% | 4.3x | $344 |
| 87880 | Rapid strep A test | 31,871 | 78.7% | 4.5x | $217 |
| 81025 | Urine pregnancy test | 26,605 | 80.9% | 5.1x | $143 |
| 82150 | Amylase blood test (pancreas enzyme) | 21,722 | 78.1% | 7.6x | $318 |
| 87804 | Rapid influenza test | 20,708 | 84.4% | 3.5x | $249 |
| 84703 | Pregnancy hormone (hCG) blood test, qualitative | 19,784 | 78.8% | 5.4x | $279 |
| 83690 | Lipase blood test (pancreas enzyme) | 18,645 | 81.9% | 4.9x | $221 |
| 82550 | Creatine kinase (CK) blood test | 17,329 | 76.8% | 7.2x | $265 |
| 82977 | GGT blood test (liver enzyme) | 17,009 | 79% | 6.3x | $117 |
| 81001 | Urinalysis, automated, with microscopy | 16,865 | 81.9% | 4.6x | $134 |
| 80048 | Basic metabolic panel (8 blood chemistry tests) | 16,723 | 85.1% | 4.4x | $408 |
| 83735 | Magnesium blood test | 16,654 | 80.8% | 6.3x | $201 |
All Pathology and Lab benchmark codes
| Code | Service | Disputes |
|---|---|---|
| 85025 | Complete blood count (CBC) with automated differential | 111,383 |
| 80053 | Comprehensive metabolic panel (14 blood chemistry tests) | 89,943 |
| 81003 | Urinalysis, automated, without microscopy | 56,251 |
| 84484 | Troponin blood test (cardiac injury marker), quantitative | 37,869 |
| 87880 | Rapid strep A test | 31,871 |
| 81025 | Urine pregnancy test | 26,605 |
| 82150 | Amylase blood test (pancreas enzyme) | 21,722 |
| 87804 | Rapid influenza test | 20,708 |
| 84703 | Pregnancy hormone (hCG) blood test, qualitative | 19,784 |
| 83690 | Lipase blood test (pancreas enzyme) | 18,645 |
| 82550 | Creatine kinase (CK) blood test | 17,329 |
| 82977 | GGT blood test (liver enzyme) | 17,009 |
| 81001 | Urinalysis, automated, with microscopy | 16,865 |
| 80048 | Basic metabolic panel (8 blood chemistry tests) | 16,723 |
| 83735 | Magnesium blood test | 16,654 |
| 87426 | SARS-CoV-2 (COVID-19) antigen test | 16,039 |
| 83605 | Lactate blood test | 14,977 |
| 85379 | D-dimer blood test (clot marker), quantitative | 14,951 |
| 82947 | Glucose (blood sugar) test | 14,195 |
| 87428 | Combined SARS-CoV-2 and influenza antigen test | 13,945 |
| 82565 | Creatinine blood test (kidney function) | 13,642 |
| 80051 | Electrolyte panel | 13,407 |
| 84520 | Blood urea nitrogen (BUN) test (kidney function) | 13,009 |
| 85027 | Complete blood count (CBC), automated, without differential | 12,278 |
| 87086 | Urine culture with bacterial colony count | 11,899 |
| 82553 | CK-MB blood test (cardiac enzyme) | 11,591 |
| 83880 | BNP blood test (heart failure marker) | 11,336 |
| 80076 | Hepatic (liver) function panel | 10,541 |
| 83874 | Myoglobin blood test | 9,269 |
| 87635 | SARS-CoV-2 (COVID-19) PCR test | 7,842 |
| 0202U | Respiratory pathogen panel (BioFire), 22 targets | 7,739 |
| 87633 | Respiratory virus panel (PCR, 12-25 targets) | 7,673 |
| 85610 | Prothrombin time (PT) clotting test | 7,478 |
| 82040 | Albumin blood test | 6,950 |
| 82247 | Bilirubin blood test, total | 6,781 |
| 84075 | Alkaline phosphatase blood test | 6,768 |
| 87637 | Combined SARS-CoV-2, influenza, and RSV PCR test | 6,759 |
| 84450 | AST blood test (liver enzyme) | 6,739 |
| 84460 | ALT blood test (liver enzyme) | 6,674 |
| 84155 | Total protein blood test | 6,638 |
| 86140 | C-reactive protein (CRP) inflammation test | 5,879 |
| 87081 | Bacterial culture, screening | 5,414 |
| 80305 | Drug screen, presumptive, read by direct observation | 5,385 |
| 84702 | Pregnancy hormone (hCG) blood test, quantitative | 5,038 |
| 85730 | Partial thromboplastin time (PTT) clotting test | 4,634 |
| 80307 | Drug screen, presumptive, instrument-based | 4,509 |
| 87040 | Blood culture for bacteria | 4,413 |
| 87631 | Respiratory virus panel (PCR, 3-5 targets) | 4,067 |
| 80069 | Renal (kidney) function panel | 3,989 |
| 81420 | Fetal chromosomal aneuploidy screening, genomic sequencing (NIPT) | 3,922 |
| 84100 | Phosphorus blood test | 3,696 |
| 84443 | Thyroid stimulating hormone (TSH) test | 3,627 |
| 87798 | Infectious agent PCR test, not otherwise specified | 3,339 |
| 86308 | Heterophile antibody screen (mononucleosis test) | 3,185 |
| 87591 | Neisseria gonorrhoeae PCR test | 3,178 |
| 87491 | Chlamydia trachomatis PCR test | 3,130 |
| 87486 | Chlamydia pneumoniae PCR test | 2,847 |
| 87581 | Mycoplasma pneumoniae PCR test | 2,787 |
| 87811 | Detection test by immunoassay with direct visual observation for severe acute respiratory | 2,505 |
| 82803 | Blood gases measurement | 2,456 |
| 86901 | Blood typing for Rh (D) antigen | 2,407 |
| 86900 | Blood group typing (ABO) | 2,337 |
| 87186 | Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or aga | 1,971 |
| 87088 | Bacterial urine culture | 1,955 |
| 87651 | Detection test by nucleic acid for Strep (Streptococcus, group A), amplified probe techniq | 1,915 |
| 84439 | Thyroxine (thyroid chemical), free | 1,845 |
| 81002 | Urinalysis, manual test | 1,808 |
| 84550 | Uric acid level, blood | 1,696 |
| 80047 | Blood test, basic group of blood chemicals (Calcium, ionized) | 1,678 |
| 87807 | Detection test by immunoassay with direct visual observation for respiratory syncytial vir | 1,670 |
| 82962 | Blood glucose (sugar) test performed by hand-held instrument | 1,621 |
| 80320 | Alcohols levels | 1,559 |
| 86850 | Screening test for red blood cell antibodies | 1,513 |
| 85007 | Microscopic examination for white blood cells with manual cell count | 1,321 |
| 83036 | Hemoglobin A1C level | 1,266 |
| 0241U | Respiratory infectious agent detection by RNA for severe acute respiratory syndrome corona | 1,261 |
| 87070 | Bacterial culture, any other source except urine, blood or stool, aerobic | 1,258 |
| 80061 | Blood test, lipids (cholesterol and triglycerides) | 1,161 |
| 87077 | Bacterial culture for aerobic isolates | 1,132 |
| 82948 | Blood glucose (sugar) measurement using reagent strip | 1,020 |
| 87507 | Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 1 | 884 |
| 87205 | Special Gram or Giemsa stain for microorganism | 866 |
| 85652 | Red blood cell sedimentation rate, to detect inflammation, automated | 852 |
| 81007 | Urinalysis for bacteria | 775 |
| 86677 | Analysis for antibody to Helicobacter pylori (gastrointestinal bacteria) | 736 |
| 87632 | Detection test by nucleic acid for multiple types of respiratory virus, multiple types or | 703 |
| 87661 | Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified pro | 669 |
| 88305 | Pathology examination of tissue using a microscope, intermediate complexity | 661 |
| 84145 | Procalcitonin (hormone) level | 607 |
| 82077 | Measurement of alcohol level in specimen other than breath or urine | 591 |
| 87420 | Detection test by immunoassay technique for respiratory syncytial virus (RSV) | 580 |
| 80074 | Acute hepatitis panel | 578 |
| 86592 | Syphilis detection test | 562 |
| 87389 | Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies | 501 |
Top states for Pathology and Lab disputes
| State | Disputes | Provider win rate | Median award |
|---|---|---|---|
| Texas | 111,815 | 78.2% | 5.1x |
| Arizona | 12,359 | 77% | 9.8x |
| Tennessee | 12,233 | 80% | 4.2x |
| California | 9,594 | 85.7% | 2.5x |
| Arkansas | 6,742 | 83.9% | 14.8x |
| Oklahoma | 6,273 | 90.2% | 9.1x |
| Mississippi | 5,454 | 83.5% | 4.7x |
| New Mexico | 3,681 | 90.6% | 5.6x |
| New Jersey | 2,697 | 81.1% | 1.0x |
| Indiana | 2,272 | 79.6% | 5.2x |
Top payers in Pathology and Lab
| Payer | Disputes | Provider win rate | Median award |
|---|---|---|---|
| BCBSTX | 71,348 | 80.7% | 5.7x |
| Cigna / MultiPlan | 19,457 | 74.1% | 3.6x |
| UnitedHealthcare | 18,545 | 76.8% | 4.0x |
| Aetna | 17,933 | 83.1% | 2.0x |
| Cigna | 11,862 | 81.5% | 4.7x |
| UMR (clearhs.com) | 9,586 | 81% | 3.8x |
| Anthem Blue Cross | 7,770 | 86.4% | 3.5x |
| BCBSAZ | 7,550 | 76.9% | 12.7x |
| AMBETTER | 5,420 | 95% | 4.0x |
| BLUE CROSS AND BLUE SHIELD OF TEXAS | 3,555 | 83.5% | 8.6x |
Filing checklist before you take Pathology and Lab claims to IDR
- Confirm the claim is NSA-eligible: emergency care, or out-of-network care at an in-network facility, with no state arbitration law that displaces the federal process for that plan type.
- Start open negotiation within 30 business days of the initial payment or denial notice. The negotiation window then runs 30 business days.
- If negotiation fails, initiate federal IDR through the portal within 4 business days after the window closes.
- Batch same-payer items in the same service code category. Open negotiation periods starting on or after November 1, 2026 can batch up to 50 line items per dispute, up from 25.
- Budget for fees: the federal administrative fee is $15 per party for disputes initiated on or after June 11, 2026 (down from $115), and the non-prevailing party pays the certified IDR entity fee.
- Anchor your offer to the data: the Pathology and Lab median provider-won award is 5.0x QPA across 195,399 disputes.
The fee and batching changes come from the May 2026 federal IDR operations final rule. See the 2026 and 2027 No Surprises Act changes guide for the full timeline, or request a free NSA audit to see how your claims compare.
Open the Pathology and Lab dashboard
Filter Pathology and Lab disputes by state, payer, and year to compare the public benchmark with your own out-of-network payment experience.
FAQ
How many Pathology and Lab federal IDR disputes are in the dataset?
This benchmark shows 195,399 Pathology and Lab disputes.
What is the Pathology and Lab provider win rate?
The non-default provider win rate is 79.9%.
What should Pathology and Lab groups compare first?
Start with service-code mix, then narrow by payer and state. That sequence usually gives a more useful answer than a national specialty average.
What changes in 2026 and 2027 affect Pathology and Lab IDR filings?
The administrative fee dropped to $15 per party for disputes initiated on or after June 11, 2026, batching expands to 50 line items for open negotiation periods starting on or after November 1, 2026, and standardized CARC/RARC remittance codes arrive January 1, 2027.
Related benchmarks
Sources and method
Providers won 85.8% of 3.39 million federal IDR disputes through 2025Q4, with a median provider-won award of 4.7x the qualifying payment amount, per CMS public use files.
- CMS: Federal IDR reports and public use files
- CMS: Federal IDR operations final rule fact sheet
- CMS: Federal IDR timeline for claims
Data source: CMS Federal IDR public use files, coverage through 2025Q4; data build 2026-09-24. Counts are CMS dispute counts unless a table says line items. Win rates on this page exclude payer no-show defaults unless labeled otherwise. Award multiples are medians versus the qualifying payment amount (QPA). Dollar figures, where shown, come from CMS QPA-and-offer fields or are anchored estimates, not payment records. This page is informational, not legal or reimbursement advice.