CPT 86738: Federal IDR outcomes
Analysis for antibody to Mycoplasma (bacteria)
In 2025 Q1–Q4, the provider or facility offer prevailed in 92.6% of 175 determined Federal IDR dispute line items for CPT 86738. The median prevailing offer was 3.18x the QPA (25th–75th percentile 1.87x–6.75x; n = 161). The median time to a decision was 36 business days (n = 175).
Determined line items
175
2025 Q1–Q4 · 0 split decisions excluded
Provider win rate
92.6%
n = 175 · 2025 Q1–Q4
Median payment vs QPA
3.18x
middle half 1.87x–6.75x · n = 161 · 2025 Q1–Q4
Median days to decision
36
business days, from dispute initiation · n = 175 · 2025 Q1–Q4
Dollar amounts
Total awarded
$15,955
sum of prevailing offers · n = 129 · 2025 Q1–Q4
Total QPA
$5,440
sum of QPAs, same line items · n = 129 · 2025 Q1–Q4
Awarded above QPA
$10,515
total awarded minus total QPA · n = 129 · 2025 Q1–Q4
Median award per line item
$110
mean $124 · n = 129 · 2025 Q1–Q4
Median QPA
$35
per line item · n = 129 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
2.93x
total awarded ÷ total QPA · n = 129 · 2025 Q1–Q4
Dollar amounts come from the separate CMS “QPA and Offers” file: line items decided for the provider or the plan with a non-suppressed QPA and prevailing offer. That file cannot be joined to the line items above, so its n differs. Awarded = the prevailing (selected) offer; it is not a record of what was paid. State comes from the file’s geographic region; a metro area that spans states counts in each. How the dollar figures work
Dollar amounts by period
| Period | Line items with $ | Total awarded | Total QPA | Above QPA | Median award | Median QPA | Award ×QPA ($-weighted) |
|---|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 129 | $15,955 | $5,440 | $10,515 | $110 | $35 | 2.93x |
| 2024 Q3–Q4 | Fewer than 30 line items with dollar amounts; not shown. | ||||||
| 2024 Q3–2025 Q4 | 129 | $15,955 | $5,440 | $10,515 | $110 | $35 | 2.93x |
| 2023 Q1–2024 Q2 | Not available (see methodology). | ||||||
From the CMS QPA and Offers file (see above). Award ×QPA here is total awarded ÷ total QPA, so large claims weigh more than in the per-line median ratio.
By period
| Period | Line items | Win % | Median ×QPA | 25th–75th | Ratio n | Median days |
|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 175 | 92.6% | 3.18x | 1.87x–6.75x | 161 | 36 |
| 2024 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–2025 Q4 | 176 | 92.6% | 3.18x | 1.87x–6.75x | 161 | not pooled |
Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.
By state
| State (place of service) | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Texas | 173 | 92.5% | 3.16x | 160 | 36 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Dollar amounts by state
| State (region) | Line items with $ | Total awarded | Median award | Median QPA | Award ×QPA |
|---|---|---|---|---|---|
| Texas | 77 | $10,362 | $110 | $39 | 3.04x |
2025 Q1–Q4 · CMS QPA and Offers file · rows with n ≥ 30 line items with dollar amounts · sorted by n · Award ×QPA = total awarded ÷ total QPA.
By specialty
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Emergency medicine and emergency departments | 168 | 92.3% | 3.18x | 157 | 36 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Section: Pathology and laboratory (80047–89398)
FAQ
What is the Federal IDR provider win rate for CPT 86738?
In 2025 Q1–Q4, the provider or facility offer was selected in 92.6% of 175 determined dispute line items for CPT 86738. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.
How do Federal IDR payments compare with the QPA for CPT 86738?
In 2025 Q1–Q4, the median prevailing offer was 3.18x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 1.87x to 6.75x (n = 161 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.
How long do Federal IDR decisions take for CPT 86738?
In 2025 Q1–Q4, the median was 36 business days (n = 175 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).