Pathology/Lab Coding Alert

See what disagreement over a blood pathogen code will cost you.

With attention to CPT^® Microbiology section guideline changes and Clinical Laboratory Fee Schedule (CLFS) final payment determinations, we have an update to help you round out coding and payment expectations for your microbiology lab in 2022.

Recall: Pathology/Lab Coding Alert, Vol. 22, No. 12, provides a rundown of Microbiology section code revisions and additions in “Consolidate Infectious Agent Changes.”

Check Out New Infectious-Agent Guidelines

CPT^® 2022 adds a paragraph to the introductory guidelines for codes 87260-87899 that helps clarify method distinctions between code families. Specifically, the guidelines help to dispel confusion surrounding the word “fluorescence” in method descriptions.

Keeping abreast of guideline changes, as well as code changes, can be important to your practice’s bottom line, according to Melanie Witt, RN, MA, an independent coding consultant from Guadalupita, New Mexico.

The following breakout walks you through the guidelines for three distinct infectious-agent-detection code families. Although CPT^® implemented many of the changes during an earlier pandemic-related update, CPT^® 2022 is the first time you’ll see the changes in the printed manual.

Microscopic: The guidelines state, “When identifying infectious agents on primary-source specimens (e.g., tissue, smear), microscopically by direct/indirect immunofluorescent assay [IFA] techniques, see 87260-87300.”

The common part of the code descriptor for 87260-87300 (Infectious agent antigen detection by immunofluorescent technique …) mentions “immunofluorescent technique,” but the new guidelines add greater clarity to the codes by specifying the following:

• The codes describe direct or indirect immunofluorescent assays.
• The codes describe a microscopic procedure.

These are methods that involve processing the specimen with fluorescently labeled antibodies specific to infectious-agent antigens of interest to allow detection of the antigen/antibody complex with a fluorescence microscope.

FIA: The guidelines state, “When identifying infectious agents on primary-source specimens or derivatives via non-microscopic immunochemical techniques with fluorescence detection (i.e., fluorescence immunoassay [FIA]), see 87301-87451, 87802-87899.”

CPT^® 2022 revises the parent code descriptor for codes 87301-87451 (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 …) to add FIA as one of the possible lab methods for these tests. Any of the immunoassay methods described in these codes involves inducing an antigen/antibody reaction in the specimen for a specific infectious agent. An instrument can detect, and often quantify, the reaction based on one of several types of “tags,” such as a radioisotope, or a reactive fluorescent molecule, or an enzyme substrate that produces a color change. The key is that these detection methods use instrumentation, not microscopic or “naked eye” evaluation.

Visual: The guidelines state, “When identifying infectious agents on primary-source specimens using antigen detection by immunoassay with direct optical (i.e., visual) observation, see 87802-87899.”

CPT^® 2022 revises the parent code descriptor for codes 87802-87899 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation …) by adding the parenthetic “ie, visual” to clarify that these tests yield a result that can be “read” by the naked eye. Tests described by these codes do not use microscopic evaluation or instrumentation to obtain the result.

Bottom line: These CPT^® 2022 guidelines reflect the code-descriptor revisions to clarify how to use these codes, says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Oregon.

Greet Blood Pathogen Microbiology Code

New code 87154 (Culture, typing; identification of blood pathogen and resistance typing, when performed, by nucleic acid (DNA or RNA) probe, multiplexed amplified probe technique including multiplex reverse transcription, when performed, per culture or isolate, 6 or more targets) makes its debut in CPT^® 2022.

The microbiology lab may perform this test following a positive blood culture using an isolate that is already identified to the genus and species level to identify the isolated organism’s taxonomic type and resistance to medications. The test uses a nucleic acid probe, which is fabricated single-strand sequences of DNA or RNA that join with the complementary target sequence from an infectious agent in the specimen.

Amplified: The code specifies that this is an “amplified” probe technique, meaning that the procedure includes amplification techniques such as polymerase chain reaction (PCR) and possibly reverse-transcription PCR to increase the number of copies of specific nucleic acid sequences, if present in the specimen.

Multiplex: Instead of having just one target, the probe for this test has nucleic acid sequences for at least six targets, making it a “multiplex” probe.

Clinicians may order this for patients with a blood infection (sepsis) following the initial culture and definitive identification of the pathogenic agent. Rapid identification of the causative organism and its resistance to common medications may be lifesaving because sepsis can be a serious final pathway to death in many infectious diseases.

If your lab performed a test similar to 87154 in prior years, you may have reported the service using 87158 (Culture, typing; other methods).

Scrutinize CLFS Final Payment Determinations

After considering input from stakeholders at the annual CLFS public meeting and responses to the Centers for Medicare & Medicaid Services’ (CMS’) preliminary payment determinations, the agency published the final payment determinations in November, as outlined by CMS’ meeting facilitator, Sarah Harding, from the CMS CLFS policy team.

With little variance from the preliminary pricing described in Pathology/Lab Coding Alert, Vol. 22, No. 12, you should be aware of two noteworthy final payment determinations that could impact your lab’s pay.

Code 87154: Although most stakeholders recommended crosswalking the payment amount for this new culture typing code to 87506 (Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets) ($262.99), CMS decided to crosswalk to 87632 (… 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, 6-11 targets) ($218.06).

Code 87428: In the preliminary determinations, CMS suggested crosswalking 87428 (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; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B) to 87400 (… Influenza, A or B, each) ($14.13) plus 87449 (… not otherwise specified, each organism) ($11.98) (total fee $26.11).

CMS changed course in the final determination, agreeing with the majority of commentators to crosswalk 87428 to 87430 (… Streptococcus, group A) ($16.81) plus 87400 (total fee $30.94).

Details: All payments listed above for existing codes reflect the CLFS national payment amount effective in the fourth quarter of 2021. Crosswalking means that the basis of payment for the new code is the payment rate for an existing code due to similarities in method and resource utilization. Alternately, CMS determines to gapfill payment for some codes that do not correlate with any existing 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 nine months, according to Harding.