Otolaryngology Coding Alert

If your office tests for flu, here's how to maximize your reimbursement

You probably don't have many patients coming to your office just because they have a cold or the flu. But many of them have problems -- such as sinus and ear infections -- that started with a cold or flu, so you should be on top of the relevant codes, especially this time of year.

The flu and the common cold are both respiratory illnesses, but different viruses cause them, the Centers for Disease Control and Prevention (CDC) says. Because these two types of illnesses have similar symptoms, your ENT may have a hard time differentiating between them based on symptoms alone. In general, the flu (487.x Influenza) is worse than a cold (460 Acute nasopharyngitis), and symptoms such as fever, body aches, extreme tiredness, and dry cough are more common and intense when a patient has the flu, the CDC says.

More info: Additional digits help you describe flu that has progressed to other medical problems:

- 487.0 -- Influenza with pneumonia

You-ll use an additional diagnosis code to describe the type of pneumonia.

- 487.1 -- Influenza with other respiratory manifestations

This code describes a patient who has laryngitis, pharyngitis, or another respiratory infection.

- 487.8 -- Influenza with other manifestations

You-ll use this when a patient has encephalopathy due to flu, or gastrointestinal problems related to the flu (but not for stomach flu, for which you-d use the appropriate code from the 008.x [Intestinal infections due to other organisms] range).

Colds are usually milder than the flu. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations. But a cold can progress to a sinus infection.

Example: A patient presents with acute sinusitis and an upper respiratory infection that have resulted from a lingering cold. You-ll code 461.9 (Acute sinusitis, unspecified) for the first-listed diagnosis, 460 for the second, and 465.9 (Acute upper respiratory infection NOS) for the third.

In-office testing: Because colds and flu share so many symptoms, it can be difficult (or even impossible) to tell the difference between them based on symptoms alone. Tests that usually must be done within the first few days of illness can be carried out to tell whether a person has the flu.

Should your ENT test a patient for influenza, coding is not always as easy as reporting 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza). Your code choice will depend on the type of test the physician conducts and what method and product she uses. Not all influenza tests that qualify for 87804 deserve multiple-unit coding-- and the same product doesn't always deserve multiple coding.

Use a modifier: Code 87804 describes the rapid flu test approved by the FDA requiring Clinical Laboratory Improvement Act (CLIA)-waived status, says Kevin Perryman, administrator at the office of Teri Perryman, MD, in Kerrville, Texas. In some cases, carriers may require you to follow Medicare guidelines and append modifier QW (CLIA-waived test) to 87804, Perryman says. To keep coding uniform, Perryman uses modifier QW regardless of payer and hasn't had any denials due to its use.

When your office uses an A&B influenza test, you should code multiple units of 87804 when appropriate. "You should report 87804 per strain tested or per result," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. Here's how you should apply the "1 Result = 1 Code" rule to three tests:

Product 1: For an in-office test that does not identify the influenza strain, report one unit of 87804. "Quidel QuickVue Influenza Test picks up only the presence of influenza with a single positive/negative result," Dettwyler says. Because the test gives you one result, you should report one unit of 87804. If you use a product that differentiates between influenza A & B, you should report 87804 twice. When you get two results from a test, you should code for two units, Dettwyler says.

Products 2 and 3: Two products that use a single test device (such as a swab) to test for different strains resulting in two results include the Quidel Quickvue Influenza A+B Test and the Binax NOW A&B Test.

Because you code per result, not per device, don't automatically code two units of 87804 every time you use a Quidel Quickvue Influenza A+B Test or Binax NOW A&B Test kit. "Clinicians do not always require both tests even if the kit can identify two types of influenza," Dettwyler says.

You code it: Your office runs the Quidel Quickvue Influenza A+B Test and tests for both strains. Test results indicate:

--positive for influenza A

--negative for influenza B.

Solution: "You should code two units of 87804: one code for each result," Dettwyler says.

Learn more about flu season at www.cdc.gov/flu/weekly/fluactivity.htm.