Overview
CPT® Code 84402 is used to report free testosterone testing in serum or plasma. Free testosterone represents the unbound, biologically active fraction of total testosterone and is crucial for evaluating endocrine function in both males and females. Measurement of free testosterone helps diagnose hypogonadism, assess fertility, monitor hormone therapy, and evaluate androgen-related disorders.
This code reflects the laboratory analysis itself, typically performed via equilibrium dialysis, ultrafiltration, or validated immunoassays. Interpretation and counseling are separate services.
Key Facts About CPT® 84402
- Service type: Clinical laboratory hormone test
- Provider type: Physicians, laboratories, and qualified healthcare professionals
- Medical services included: Quantitative measurement of free testosterone
- Specimen type: Serum or plasma
- Common clinical indications:
- Diagnosis of hypogonadism or androgen deficiency
- Evaluation of infertility in men or women
- Monitoring testosterone replacement therapy
- Assessment of polycystic ovary syndrome (PCOS) or other endocrine disorders
When to Use CPT® 84402
CPT 84402 is appropriate when:
- A serum or plasma sample is collected specifically for free testosterone measurement
- Testing is medically necessary to guide diagnosis or treatment
- Results will inform clinical decisions, such as hormone replacement therapy or reproductive evaluation
Examples:
- Evaluating a male patient with fatigue, low libido, or delayed puberty
- Monitoring a female patient undergoing therapy for hyperandrogenism
- Assessing hormonal status in fertility investigations
Documentation Requirements
To properly support CPT 84402 billing, documentation should include:
- Patient identifiers and date of specimen collection
- Sample type (serum or plasma)
- Indication for testing
- Method used (e.g., equilibrium dialysis, immunoassay)
- Test results and follow-up recommendations
Accurate documentation ensures proper reimbursement, compliance, and integration with the patient’s medical record.
Reimbursement and Coding Considerations
- CPT 84402 is generally covered by commercial insurers, Medicare, and Medicaid when medically necessary
- Interpretation or counseling is not included and billed separately if provided
- Modifier usage may be required if multiple hormone tests are performed on the same specimen
- Always verify payer-specific rules for lab testing and bundling
How OptiMantra Supports Free Testosterone Testing
OptiMantra’s integrated EMR and practice management platform simplifies lab workflows for CPT 84402:
With OptiMantra, providers can:
- Automatically link free testosterone orders to patient charts
- Track hormone trends over time for informed clinical decisions
- Document indications, methods, and follow-up recommendations within the EMR
- Generate audit-ready, compliant billing codes for lab services
- Integrate free testosterone results into broader care plans for endocrine or fertility management
By centralizing lab documentation, tracking, and billing, OptiMantra ensures accuracy, compliance, and smooth workflows for hormone testing.
Try OptiMantra for free here!
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