Oncology & Hematology Coding Alert

Confirm CLIA certification for your practice; document influenza strains A and B.

The plethora of influenza virus strains makes it a challenging job to test for flu. You will find yourself in difficult situations when you need to report flu testing for multiple strains. Your provider will commonly do office testing for flu. Don’t let flu testing compromise your payment.

For Medicare, and some private payers, you’re going to need to include a modifier whether the provider tests for single or multiple flu strains. For encounters where your provider tests for more than one flu strain, you’ll need an additional modifier to separate the tests and maximize reimbursement.

Here is what experts have to say for testing for multiple strains of influenza.

ID 87804 Test Before Choosing Code

If you’re performing a test that detects the flu via immunoassay in the office, you’ll report the service with 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza), says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

Though it’s a common screening in most medical practices, you must positively identify the 87804 flu test before coding or you could face denials.

The flu test that the 87804 code represents “is a testing platform that yields a typically qualitative result by producing a signal on the reaction chamber,” explains Melanie Witt, MA, an independent coding consultant in Guadalupita, N.M. The provider can then interpret the results visually, via a colored band or some other machination (the “direct optical observation” that the 87804 code descriptor mentions).

If the test fits all the parameters put forth in its code descriptor, you should report 87804 for your provider’s flu test.

Keep QW Handy For Medicare Patients

When coding for Medicare, remember that 87804 is a Clinical Laboratory Improvement Amendments (CLIA) waived test. Even if your practice does not have a CLIA certification, you can perform this flu test and report it.

When you are performing the CLIA waived test, be sure to append modifier QW (CLIA-waived test) to indicate the test type. The QW modifier is only required for Medicare payers, but some private payers might also want you to use QW. Check with your top payers about their QW policies, in case they have specific requirements.

Best bet: If you are unsure whether an insurer requires modifier QW for 87804, call and check before filing your claim. “Each payer may have its own requirements as to whether the QW is required, but it would be appropriate to append if the test is indeed CLIA-waived,” says Sarah L. Goodman, MBA, CPC-H, CCP, FCS, president/CEO and principal consultant at SLG, Inc., in Raleigh, N.C. 

For a list of CLIA-waived tests, see www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf.

Opt for 59 Rather Than Reporting Multiple Units of 87804

Once you’ve determined that your provider performed an 87804 flu test, you’re ready to check if the patient was tested for both strains A and B of the flu.

While it is possible for the provider to test for only one strain of the flu, physicians will often test for strains A and B during the same encounter. When your provider performs this test in the office to identify both flu strains A and B, you’ll be able to report 87804 twice. In order for the claim to sail through, however, you’ll need help from a modifier — or modifiers, depending on the payer.

“If the assays provide two separate results — a result for influenza virus A and a result for influenza virus B

— it would be appropriate to report two units of code 87804,” confirms Witt. Mac advises coders to list 87804 on two lines with modifier 59 (Distinct procedural service) appended to the second unit of 87804. This is preferable to reporting the code twice on the same line, in her experience. Mac reports seeing claims with 87804 x 2 on one line, and the second flu test code was “completely ignored” by the payer. When you test for flu types A and B, “you get better responses with 87804-59 on the second line,” she says.

Caveat: Keep in mind that CMS introduced the X modifiers (XU, XS, XP, XE) and your payer may want to see one of those instead. Modifier definitions are as follows:

• XU — Unusual non-overlapping service for a service that is distinct because it does  not overlap usual components of the main service
• XS — Separate structure for a service that is distinct because it was performed on a separate organ/structure
• XP — Separate practitioner for a service that is distinct because it was performed by a different practitioner
• XE — Separate encounter for a service that is distinct because it occurred during a separate encounter

Document Both Flu Tests, Reduce Denial Possibility

You should also properly support your multiple flu test claims with the accurate and specific documentation, Mac advises. Before you send in your 87804 claims, be sure to check the documentation to see if the provider was specific enough to prove to payers that he tested for strains A and B. If you don’t have documentation clearly delineating the tests’ objectives, the payer, understandably so, may question reimbursing two units of 87804.

“Be sure you document the findings for both [flu] tests,” Mac says. “Instead of saying, ‘Flu strains negative,’ say it twice: Say ‘Flu strain A is negative. Flu strain B is negative,’ because that information could get lost by the payer if it’s not spelled out.”