Pathology/Lab Coding Alert

With numerous Helicobacter pylori lab tests scattered throughout the CPT pathology/laboratory section and beyond, you might need some help finding the right code. In breath, blood, biopsy, or stool, numerous tests help physicians track down signs of H. pylori infection that can lead to peptic ulcer disease. Our experts break down your coding choices and show that your selection primarily depends on lab method and specimen source.

H. pylori produces an enzyme called urease that neutralizes stomach acid and enables the bacteria to thrive in the gut. Clinicians have turned this feature into a handy test platform -- find the urease and you've found an indication of H. pylori.

• For urease activity in blood specimens, report 83009 (Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope [e.g., C-13]).

For urease activity in breath specimens, you have two choices based on the carbon isotope used for testing. Both C-14 (radioactive carbon) and C-13 (heavy carbon) tests require the patient to ingest urea, which H. pylori metabolizes into exhaled CO2 that the lab then measures.

• C-14 breath test: You should report the administration of the C-14 breath test with 78267 (Urea breath test, C-14 [isotopic]; acquisition for analysis). For the laboratory breath analysis using a liquid scintillation counter to quantify the C-14 present in exhaled breath, you should report 78268 (... analysis).

Don't forget: If your lab provides the radioactive isotope for this procedure, you should include A4641 (Radiopharmaceutical, diagnostic, not otherwise classified).

• C-13 breath test: You should use 83014 (Helicobacter pylori; drug administration) and 83013 (Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope [e.g., C-13]) for H. pylori breath test based on C-13 technology for diagnosis, says Joel V. Brill, MD, AGAF, chief medical officer at Predictive Health LLC in Phoenix. The lab detects the amount of C-13 in the exhaled breath specimen using a method such as mass spectrometry.

Blood antibody tests provide an immunologic method to diagnose H. pylori infection. "Two codes describe serologic H. pylori antibody tests based on the complexity of the lab method," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Choose the code based on the complexity of the lab method as follows:

• 86318 -- Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (e.g., reagent strip).

Physician office labs commonly use this test to provide a rapid, qualitative detection of IgG antibodies for H. pylori in the blood. Laboratories operating under a Clinical Laboratory Improvement Amendments (CLIA) certificate of waiver can conduct this test and should report the code with modifier QW (CLIA-waived test). CLIA lists 28 test kits approved for this code.

• 86677 (Antibody; Helicobacter pylori).

Multiple step is key: According to CPT instruction, tests in this family "are qualitative or semiquantitative immunoassays performed by multiple-step methods for the detection of antibodies to infectious agents."

"The distinguishing characteristic for this code is 'multiple step' rather than a single-step method described by 86318," Dettwyler says.

CPT provides two codes for noninvasive tests that detect H. pylori antigens based on enzyme methods:

• 87338 -- Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Helicobacter pylori, stool

• 87339 -- ... Helicobacter pylori

"This code describes a test similar to 87338 that the lab performs on a non-stool specimen, such as blood, serum, gastric, urine, or saliva. Make sure the kit you're using is approved for the particular specimen," Dettwyler says.

A "campylobacter like organism" (CLO) test is a direct bacterial assay, usually by a commercial kit that uses rapid urease testing. "A physician may order a CLO test in conjunction with endoscopy and stomach biopsy to identify H. pylori infection," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Report a CLO test as 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate), even though the most accurate code is 87081 (Culture, presumptive, pathogenic organisms, screening only).

Here's why: "Code 87077 actually describes additional biochemical methods -- such as urease activity -- to definitively identify a culture specimen. The code does not describe a test kit for direct-source urease activity," Dettwyler says. "But when CPT 2001 removed the CLO test code (87072, Culture or direct bacterial identification method, each organism, by commercial kit, any source except urine), it directed coders to use code 87077 instead."

CMS now lists all CLIA-waived CLO tests as 87077-QW.

Tip: Write "CLO test" next to 87077 in your CPT book to help you remember this coding.

Despite different methods and different specimen sources, payers often won't cover more than one H. pylori test because they provide similar diagnostic information. For instance, the Correct Coding Initiative (CCI) bundles the two urea breath tests (83014 and 78267) as a mutually exclusive edit pair.

Many payers also have guidelines for test frequency. For example, National Government Services has a local coverage determination (LCD) that states, "Once positive, serology for H. pylori will only be paid one time, since the presence of antibodies can persist for a long period of time." You can read the entire LCD at www.ngsmedicare.com/NGSMedicare/newjpolicy/policy/l3835_final.htm.

Best advice: Check your state's Medicare carrier for similar restrictions.