Part B Insider (Multispecialty) Coding Alert

If you always reach for 87804, you could be mis-coding

When your family physician tests a patient for influenza, coding is not always as easy as reporting code 87804.

Your code choice will depend on the type of test the physician conducts and what method and product she uses. Use this simple guide to determine the correct number of in-office influenza test units and the appropriate modifiers.

Take note: Not all influenza tests that qualify for 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza) deserve  multiple-unit coding--and the same product doesn't always deserve multiple coding.

Two lab experts make complex in-office flu test coding easy.
 
Report 87804-QW for Optical Analysis
 
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. Use this code for detection by visual identification, rather than by DNA or RNA as represented by 87797 and 87798 (single analyte determination) or 87800 (multiple analyte determination B), which are for the non-CLIA-waived flu test typically done in facility-based and independent laboratories.

Part B tip: Many Medicaid states require you to follow Medicare modifier guidelines and append modifier QW (CLIA-waived test) to 87804, Perryman says. To keep coding uniform, Perryman uses modifier QW regardless of payor and hasn't had any denials due to its use.
 
Apply 87804 Coding Rule to 3 Flu Products
 
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:

- Quidel Quickvue Influenza A+B Test
- 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.
 
Consider 2 Alternatives for 87804 Denial
 
You may confront variations in the way payors require you to report multiple units of 87804. Here's how to decide which method to use:

Best practice: Report two units of 87804 if the payor allows it. -Billing the same code more than once is appropriate when you perform testing for two results,- Dettwyler says.

For payors that do not recognize two units of 87804 and deny the second charge as a duplicate, use modifier 59 (Distinct procedural service) on the second 87804 entry. -This modifier indicates that a different test was performed to test for a distinct strain,- Dettwyler says.

Fallback method: Because some contractor and insurer computer systems do not recognize modifier 59, you may instead need to use modifier 91 (Repeat clinical diagnostic laboratory test). In this case, you should communicate with the payor to determine if modifier 91, which is uniquely applicable to laboratories, would be a reasonable alternative, suggests the American Society for Microbiology in its -Q & A- on 87804 and 87804-59.

Before using this coding method, which contradicts current coding guidelines, obtain a written recommendation from the payor.