Pathology/Lab Coding Alert

Although the CPT 2001 revisions, additions and deletions of the microbiology codes for culturing pathogenic organisms (87040-87158) systematized coding based on the culture source, type of organism and level of identification, many pathology Coder have questions about how to use these codes. The key to using the microbiology codes for appropriate reimbursement lies in understanding that if a test for presumptive identification is followed by a definitive test, both codes should be reported. If additional identification tests are conducted to type isolates more specifically, the appropriate code(s) should be reported as well.

Twenty-three of the 28 culture codes in the 87040-87158 range are new or revised in CPT 2001. Additionally, 11 codes were deleted from that code range. Most of the changes differentiate presumptive and definitive identification and specify the source and type of organism being cultured, says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla.

Coding Bacterial Cultures

1. Source: Blood. Report isolation and presumptive identification of either aerobic and/or anaerobic bacterial cultures from blood using 87040 (culture, bacterial; blood, with isolation and presumptive identification of isolates [includes anaerobic culture, if appropriate]). This culture typically involves aerobic and anaerobic test bottles that are analyzed for bacterial growth by various laboratory methods. Following isolation and presumptive identification, if the bacteria are then definitively identified, coders should also report either 87076 ( anaerobic isolate, additional methods required for definitive identification, each isolate) for anaerobes, or 87077 ( aerobic isolate, additional methods required for definitive identification, each isolate) for aerobes. These codes should be reported for each isolate definitively identified. These same two codes are used for definitive identification of bacteria from sources other than blood. The methods for these two tests involve standard techniques of special media and biochemical testing. Culture typing by other methods is reported using 87140-87158.

2. Source: Stool. Report identification of Salmonella and Shigella species from stool samples using 87045 ( stool, with isolation and preliminary examination [e.g., KIA, LIA], Salmonella and Shigella species). This test involves plating the organism onto specific types of agar that encourage growth of these two enteric organisms, Dettwyler explains. So this test is a presumptive identification based on growth on selective media, although CPT doesnt use that terminology for this code.

If the lab cultures for additional stool pathogens, report 87046 ( stool, additional pathogens, isolation and preliminary examination [e.g., Campylobacter, Yersinia, Vibrio, E. coli 0157]) for each plate. Based on the wording additional pathogens, 87046 should only be reported following the initial stool culture (87045), Dettwyler says. If the physician orders only a screening for a specific organism such as pathogenic E. coli, that service should be reported with 87081 (culture, presumptive, pathogenic organisms, screening only).

If you look at the wording in 87046 and the pricing information for these tests, it appears that the intention is to report it when a special plate for additional pathogens is performed with a stool culture, says Scott Treida, MT (ASCP), senior chargemaster consultant with Healthcare Consulting Services LLC in Indianapolis. The 2001 Clinical Laboratory Fee Schedule states, New code 87046 is priced at one-quarter of the rate of code 87045. (See HCFA program memorandum AB-00-109.)

3. Source: Urine. Bacterial urine culture with a quantitative colony count is reported using 87086 (culture, bacterial; quantitative colony count, urine). Isolation and presumptive identification of the bacterial urine culture is reported as 87088 ( with isolation and presumptive identification of isolates, urine). These two codes can each be reported if both a quantitative colony count and presumptive identification are carried out. However, I believe that because only one culture is involved, these codes partially represent the same service and should be represented by one code similar to 87040 for blood cultures, Dettwyler says. Although it may be acceptable, I dont think you should report 87086 and 87088 together. If definitive bacterial identification is required for a urine culture, CPT 87077 should also be reported for each aerobic isolate identified.

Treida claims that based on the CPT language, 87086 should be billed for the test to determine if clinically significant bacteriuria is present. In addition, it appears that 87088 should be reported with 87086 if an isolation and presumptive identification of a pathogen is also performed.

Based on the CPT definition of presumptive and definitive identification, it appears that 87077 may be reported in addition to 87086 and 87088. However, the reporting of three codes for a definitive bacterial culture identification runs counter to how other culture sources are handled in CPT. Treida believes that additional clarification is required regarding this issue.

4. Source: Any Other than Blood, Urine or Stool. For presumptive identification of aerobic bacteria from any source other than blood, urine or stool, use 87070. The report should identify the source, which may originate from wound, abscess, throat, nose, etc. If an aerobic quantitative culture and presumptive identification is carried out, use 87071. For definitive identification of isolated aerobes, coders should also report 87077.

For presumptive identification of anaerobic bacteria from any source, use 87075. This may include cultures from surgically collected deep abscess or tissue, for example. For quantitative anaerobic cultures from any source other than blood, urine or stool that are isolated and presumptively identified, report 87073. If either of these services is followed by a definitive identification of the isolated anaerobe, 87076 should be reported as well.

5. Screening Only. If a physician requests a culture(s) to screen for specific pathogenic organism(s), report 87081. These may come from any source, and will usually be requested based on the suspected organism. This test is commonly used to report screening for gonorrhea or group A Streptococcus, Dettwyler says. If the screening is only for presumptive identification, report 87081. However, if the culture also includes quantification, report 87084 instead.

Other Pathogen Cultures

Fungus: Report 87101 for a fungi culture with presumptive identification from dermatophytes (skin, hair or nail). For fungi culture and presumptive identification from any other source, use 87102 except blood, which is reported with 87103. If the presumptive identification is followed by definitive identification, also report 87106 for a yeast culture or 87107 for a mold culture. These two codes should be reported once for each organism identified, Dettwyler says.

Mycobacterium: Report 87116 for isolation and presumptive identification of acid-fast bacilli such as Mycobacterium tuberculosis. The source is typically body fluids or tissues. An acid-fast stain is usually carried out concurrent with culturing the specimen and should be coded separately using 87206 (smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types). If further testing is required for definitive identification, additionally report 87118 (culture, mycobacterial, definitive identification, each isolate). However, if identification is by nucleic acid probe, report 87149, or by gas liquid or high pressure liquid chromatography (GLC or HPLC), report 87143.

Mycoplasma: Report 87109 for mycoplasma culture from various sources. Common sources include bronchial washing or genital swabs. There are not separate codes for presumptive or definitive identification of these organisms.

Chlamydia: Chlamydia culture from any source is reported as 87110. Common sources include swabs from cervix, rectum, urethra and conjunctiva. This code reports identification of chlamydia infection by culture technique only. Other techniques for identifying chlamydia infection are reported with other codes, such as infectious agent antigen detection by immunofluorescence (87270), enzyme immunoassay (87320) or probe techniques (87490-87491).

Additional Identification Techniques

When additional specialized tests are used to further type the pathogenic isolates, they should be reported in addition to the presumptive and/or definitive culture codes. These include immunofluorescent culture typing (87140), other immunologic methods such as agglutination groupings (87147), GLC or HPLC (87143), nucleic acid probe (87149), pulse field gel typing (87152) and any other methods not listed (87158).

Related Scenarios

Dettwyler offers solutions to some problems and questions related to the revised culture codes.

Problem: There is confusion about the difference between 87070 (culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates) and 87071 (... quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool). It appears that the only difference between the codes is the term quantitative. The same distinction occurs with the anaerobic codes (87073, ... quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool and 87075, ... any source, anaerobic with isolation and presumptive identification of isolates). Many pathology coders ask if the routine, four-quadrant plate streaking is considered quantitative, or if the calibrated loop is quantitative.

Solution: Codes 87073 and 87075 are for anaerobic bacteria as stated in their definitions. Codes 87070 and 87071 are for aerobic bacteria, although the term does not appear in the language of 87070.

The primary difference between 87070 and 87071 is the term quantitative. Use 87070 when the culture is used only for isolation and presumptive identification of aerobic bacteria and no density estimation is made. This would be a technique such as the basic streak plate. However, sometimes an estimation of the level of bacterial contamination is needed, such as cultures from a burn patient. If a method such as the calibrated loop is used to quantify the culture, report 87071. This procedure generally involves grinding the specimen and emulsifying it to known concentrations, then spreading with a calibrated loop.

The term quantification is the only difference between 87073 and 87075. These anaerobic cultures may be used for specimens such as a culture from a bowel surgery for peritonitis. For isolation and presumptive identification, use 87075, and for the same with quantification, report 87073.

Problem: Labs often conduct a single urine culture for a colony count, plus tests, such as indole, to identify isolates. Coders wonder whether both 87086 and 87088 should be reported even though it is only one culture. If additional methods are used for more definitive identification, should 87077 also be reported? It may seem excessive because under the old codes, 87086 was used for urine culture (CPT 2000 definition: culture, bacterial urine; quantitative colony count) and 87088 for any tests for identification (CPT 2000 definition: identification in addition to quantitative or commercial kit). Now it may appear as if there are three codes to report the work that used to be covered by two codes.

Solution: In CPT 2001, three codes (87086, 87088 and 87077) describe the urine culture quantification and identification that could have previously been represented by two codes (87086, 87088). Both 87086 and 87088 were modified in CPT 2001. The microbiology codes were changed to differentiate between presumptive and definitive identification. Codes 87077 (new in 2001) and 87076 (revised in 2001) are now used to report additional methods for definitive identification to the genus or species level of aerobic or anaerobic bacteria from various sources (including urine). Therefore, 87088 was changed to represent the culture with isolation and presumptive identification of isolates from urine culture.

Although only one urine culture is carried out for quantification and presumptive identification, based on the CPT terminology, you can report both 87086 (quantification) and 87088 (presumptive identification). However, it would appear that these codes are redundant since the pathologist is plating only once. Also report 87077 for any additional tests for definitive identification of isolates.

Problem: Some pathology coders wonder how to use the revised codes to report urine cultures and the different levels of organism identification. If a urine culture is positive and a pathogen is presumptively identified, should you report 87086 and 87088? If a urine culture is positive and a pathogen is definitively identified (for example, by Vitek panel), should you report 87086 and 87077? If a urine culture is negative, should you report 87086?

Solution: If the urine culture is positive and the pathogen presumptively identified but not quantified, report 87088. If you conduct a quantitative colony count as well, also report 87086.

If you do a urine culture with quantification, followed by an automated Vitek panel for definitive identification, report 87086 and 87077. However, a Vitek panel may also be run for susceptibility tests following identification of the organism. The susceptibility studies are reported using 87181-87190, and if the Vitek panel is run for this purpose, the appropriate code should be listed in addition to any presumptive or definitive identification tests. Code 87086 would best represent the service provided by a urine culture that is negative.

Problem: A common question coders ask is, if the pathologist identifies Group A beta Streptococcus or Staphylococcus aureus by latex agglutination from the isolates of a culture, is that a presumptive identification since he or she only tested for that specific organism? Similarly, if the pathologist identifies Hemophilus influenzae by X and V strips, is that a presumptive identification since it is only one test?

Solution: Presumptive identification refers only to cultures identified by colony morphology growth on selective media, Gram stains or up to three tests such as catalase, oxidase, indole or urease. If you culture an organism, then conduct additional tests on the isolates to identify definitively the microorganisms, you would report that service in addition to presumptive identification.

For example, you would report 87147 (culture, typing; immunologic method, other than immunofluoresence [e.g., agglutination grouping], per antiserum) for the latex agglutination test to identify definitively and type organisms such as Staphylococcus aureus. Similarly, if you isolate and presumptively identify the Hemophilus, then plate the isolate on a specialized media and apply X, V and XV strips to determine definitively if the organism is Hemophilus influenzae, you would report 87077 for the X and V strip test.