Pathology/Lab Coding Alert

Heed payer coverage rules to get the pay you deserve.

When a patient presents with persistent indigestion or stomachache that won’t respond to treatment, the physician’s next step might be to send a lab test order your way to check for the presence of Helicobactor pylori (H. pylori). That’s because the pesky bacteria is at the root of intractable dyspepsia often associated with gastric, peptic, and duodenal ulcers.

How you code an H. pylori test depends on the specimen and the specific lab test you perform — and whether you get paid depends on a strict set of coverage guidelines you need to know. Read on to let our experts help you get through the H. pylori clinical lab test maze.

Distinguish Urease Tests With These Codes

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 the presence of H. pylori.

If the lab receives a blood specimen for urease activity testing, report 83009 (Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope [e.g., C-13]).

Breath test is different: The physician might order a urease breath test, which involves determining if the patient has urease activity in the gut. The test involves two steps — administering oral urea to the patient, and later measuring exhaled carbon dioxide to indicate the breakdown of urea by urease, if present.

There are two types of H. pylori breath tests, and each test requires two steps — administering the test, and evaluating the results. The difference in the tests is whether the oral urea is labeled with a radioactive carbon isotope (C-14) or a heavy carbon isotope (C-13).

Which codes your lab reports depends on the type of urease breath test, and which steps you perform at the lab. Report the test administration and analysis codes if the lab performs both steps — giving the patient the oral urea dose, and measuring the carbon dioxide in the breath sample.

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).

C-13 breath test: You should code the administration of the C-13 breath test with 83014 (Helicobacter pylori; drug administration) and the lab analysis with 83013 (Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope [e.g., C-13]). The lab detects the amount of C-13 in the exhaled breath specimen using a method such as mass spectrometry.

Check Out These Antigen/Antibody Tests

Aside from urease activity, labs may also perform tests to detect H. pylori based on the presence of the organism’s antigens in stool or other specimens.

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

• 87338 — Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool
• 87339 — ... Helicobacter pylori

Code 87339 describes a test similar to 87338 that the lab performs on a non-stool specimen, such as blood, serum, gastric, urine, or saliva. Labs often use kits for this test, and you should ensure that the kit you’re using is approved for the particular specimen.

Look for antibody tests, too: 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, as follows:

• 86318 — Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (e.g., reagent strip)
• 86677 — Antibody; Helicobacter pylori.

Physician office labs commonly use 86318 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 35 test kits approved for this code.

Reserve 86677 for more complex H. pylori antibody tests. According to CPT^® instruction, tests in the code family that includes 86677 “are qualitative or semiquantitative immunoassays performed by multiple-step methods for the detection of antibodies to infectious agents. For immunoassays by single-step method (e.g., reagent strips), use code 86318.”

Ensure Medical Necessity before Administering H. pylori Tests

Most payers have strict conditions for covering clinical H. pylori tests, such as excluding the tests if the physician performs a more invasive procedure such as an endoscopy to diagnose an ulcer.

For instance: “Before coding for a breath test, you have to ensure that patient has not had an upper gastrointestinal endoscopy within the preceding six weeks and does not have an upper gastrointestinal endoscopy planned,” explains Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel. That’s because most Medicare payers consider the breath test to be medically unnecessary for such patients.

Another example: Aetna considers carbon isotope (C-13 or C-14) urea breath testing or stool antigen testing medically necessary only for patients who meet one of the following criteria:

1. Evaluation of new onset dyspepsia
2. Evaluation of persons with persistent symptoms of dyspepsia despite two weeks of appropriate antibiotic therapy for H. pylori
3. Recurrent dyspeptic symptoms suggesting re-infection with H. pylori
4. Re-evaluation to assess success of eradication of H. pylori infection.

Moreover, Aetna does not pay for urea breath testing and stool antigen testing if done for all other indications, including risk of developing dementia, dyspepsia associated with “alarm” markers such as, anemia, gastrointestinal bleeding, obstruction, perforation, anorexia, early satiety, or weight loss (upper gastrointestinal [GI] endoscopy is indicated), or screening of asymptomatic persons for H. pylori infection.

Bottom line: Check payer rules, and inform physician clients of coverage restrictions before performing and billing for any of the various clinical H. pylori tests.