Pathology/Lab Coding Alert

Check out CLFS pricing recommendations.

Despite numerous “new” CPT^® 2022 codes for SARS-CoV-2 testing, you may already be familiar with many of the codes that had implementation dates in 2020 or 2021. Now the Centers for Medicare & Medicaid Services (CMS) has released the preliminary 2022 basis of payment for new codes on the Clinical Laboratory Fee Schedule (CLFS).

The new codes accompany numerous revisions to infectious agent detection codes in CPT^® 2022, so you have a lot to digest to ensure appropriate billing and reimbursement for these services next year. Read on for our experts’ insights on the changes.

Understand CLFS Pricing

An annual public meeting is part of the process to determine the basis of payment for new codes on the CLFS, according to CMS’s meeting facilitator, Sarah Harding, from the CMS CLFS policy team.

Weighing input from the public and advisory panels, the agency provides preliminary payment determinations in September, and finalizes the basis of payment in November. The agency may crosswalk a new code to an existing code, establishing the same payment, or gapfill the new code. Gapfilling allows Medicare Administrative Contractors (MACS) to establish payment for the code, then report the amounts to CMS, which then establishes a national payment amount — a process that may take about 9 months.

Check Out 87301 Family Revisions

Although you may have learned about the following changes earlier in the pandemic, they’ll appear for the first time in the CPT^® 2022 manual.

For codes 87301-87451, CPT^® 2022 removes the term “multiple-step method” and adds the test method, fluorescence immunoassay [FIA], for the parent code descriptor: 87301 (Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41). The definition preceding the semicolon follows to all child codes through 87430, including the following two codes that are new to the CPT^® 2022 manual:

• 87426 (… severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) (effective date June 25, 2020)
• 87428 (… severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B) (effective date Nov. 10, 2020)

The CLFS proposes to gapfill payment for 87426, and crosswalk payment for 87428 to payment rates for influenza A or B immunoassay (87400) plus unspecified organism immunoassay code (87449).

The CPT^® 2022 manual also includes for the first time in this family the following amplified probe antigen detection tests:

• 87636 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique) (effective date Oct. 6, 2020)
• 87637 (… severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique) (effective date Oct. 6, 2020)

The CLFS preliminary payment determination crosswalks both of the above codes to 87631 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets).

You won’t find deleted code 87450 (Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [eia], enzyme-linked immunosorbent assay [elisa], immunochemiluminometric assay [imca]), qualitative or semiquantitative; single step method, not otherwise specified, each organism) in CPT^® 2022 (deleted Oct. 6, 2020, but appeared in CPT^® 2021 manual). All codes through 87451 are now child codes under 87301.

Learn More 87802 Family Changes

The CPT^® 2022 manual includes a revision, announced earlier in the pandemic, to all codes in the range 87802-87899 to spell out that the term “direct optical observation” means a “visual” observation, as seen in parent code 87802 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B).

This code family also includes 87811 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])), which became effective Oct. 6, 2020, but appears for the first time in the CPT^® 2022 manual.

Key: Taken together, the revisions to the 87301 and 87802 families clarify “the proper reporting for antigen tests that are read by a machine, as compared to those which can be visually interpreted without a machine,” according to the AMA.

“For infectious agent antigen detection, use codes 87301-87451 for instrumented immunoassay tests, and 87802-87899 for visually-read immunoassay tests,” says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

CPT^® 2022 adds the following text note: “For infectious agent antigen detection by immunoassay technique, see 87301-87451. For infectious agent antigen detection by immunoassay technique with direct optical [i.e. visual] observation, see 87802-87899.”

Don’t Miss COVID-19 Antibody Codes

You’ll find three new codes in the CPT^® 2022 immunology section for SARS-CoV-2 (COVID-19) antibody testing:

• 86408 (Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen) effective date Aug. 10, 2020; gapfill
• 86409 (…Titer) effective date Aug. 10, 2020; gapfill
• 86413 (Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) antibody, quantitative) effective date Sept. 8, 2020; gapfill

Clarifying notes also appear in CPT^® 2022 immunology section directing coders to the 87301 and 87802 families for infectious agent antigen detection by immunoassay, and to three codes in the chemistry section of immunoassay tests for non-infectious agent antigens (83516, 83518, 83519, Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; …).

Recognize SARS-CoV-2 PLA Codes

The CPT^® 2022 manual includes for the first time, the following proprietary laboratory analyses (PLA) codes that describe tests for the SARS-CoV-2 virus that causes COVID-19.

• 0223U (Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected) effective date June 25, 2020; crosswalk to 87633 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets)
• 0224U (Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), includes titer(s), when performed) effective date June 25, 2020; gapfill.
• 0225U (Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected) effective date Aug. 10, 2020; crosswalk to 87633
• 0226U (Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum) effective date Aug. 10, 2020; gapfill
• 0240U (Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected) effective date Oct. 6, 2020; crosswalk to 87631
• 0241U (Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected) effective date Oct. 6, 2020; crosswalk to 87631.