Pathology/Lab Coding Alert

Diagnosis of peptic ulcer disease (PUD, 533.x) and certain other gastric disorders is often linked to the presence of Helicobactor pylori, a urease-producing bacterium. Myriad procedures identify the organism, and they are scattered throughout the pathology section and elsewhere in the CPT manual . Correctly reporting these services depends on an understanding of the laboratory procedure involved and the source of the specimen for testing.
 
Various tests for H. pylori may be ordered to aid in the diagnosis of PUD and, in some cases, to follow the effectiveness of treatment. "Because lab methods and codes for these tests have been changing in recent years, coders need to be aware of the changes and the coverage issues involved," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla. Through Correct Coding Initiative (CCI) edits and local medical review policies (LMRPs), Medicare defines coverage and frequency limitations of H. pylori tests for diagnostic or post-treatment purposes and restricts payment for multiple tests for the same patient.

Serologic Antibody Tests

"Antibody tests carried out on blood samples provide an immunologic method for primary diagnosis of H. pylori infection," Dettwyler says. However, these markers are not indicated for post-treatment evaluation because the antibodies remain in the blood for a year or more follow-ing an active infection. "There are two codes for H. pylori antibody, based on the complexity of the lab method involved," Dettwyler says.
 
The test coded with 86318 (immunoassay for infectious agent antibody, qualitative or semiquantitative, single-step method [e.g., reagent strip]) is commonly used in physician office labs 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)," Dettwyler says.
 
CPT states that codes in the family 86677 (antibody; Helicobactor pylori) represent "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.

Biopsy Culture and Histology

When a patient's condition warrants, an endoscopic gastric biopsy may be conducted. "Several tests might be carried out directly on the biopsy tissue, as well as on cultures grown from the specimen," says Leah J. Barrett, BS, MT (ASCP), assistant director of the University of Virginia Center for Studies of Diseases Due to H. pylori, in Charlottesville, Va.
 
"We typically process a Gram stain smear directly from the biopsy and culture the tissue to definitively identify the infecting organism," Barrett says. "We may also conduct a CLO test directly from the biopsy specimen for a rapid presumptive identification of H. pylori." These services have three codes:
 

87070 culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates ("The presumptive identification of the organism involves culture morphology, Gram stain and growth on selective media," Barrett says.)
 

87077 culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate.

87205 smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types (This code reports the direct smear Gram stain.)
 
 
The results of tests for catalase, urease and oxidase activity are used for definitive identification of the H. pylori organism. Both 87070 and 87077 should be reported for the culture and definitive identification.
 
Until Dec. 31, 2000, the CLO test (and other manufacturers' tests for presumptive identification of H. pylori in gastric biopsy tissue) was reported using 87072 (culture or direct bacterial identification method, each organism, by commercial kit, any source except urine). With the deletion of that code in CPT 2001, coders were directed to report the new code 87077. Following suit, the list of CLIA-waived tests changed the code for the CLO test and similar tests from 87072-QW to 87077-QW.
 
Dettwyler says, "This was an unfortunate change that leaves coders in a dilemma." Code 87072 in CPT 2000 described a "culture or direct bacterial identification by commercial kit," and it was the latter part of that code that characterized the CLO test, which detects the preformed urease of H. pylori and does not require bacterial growth. "Code 87077 describes the definitive identification of a culture, requiring additional tests beyond the three or four used for the initial presumptive identification," Dettwyler says.
 
"Code 87077 certainly does not describe the procedure used in the CLO test," Dettwyler claims. "In fact, all the codes from 87040 to 87118 represent culture techniques, and none allow for direct bacterial identification as did code 87072." This leaves coders in the difficult situation of deciding whether or not to follow AMA and CLIA direction to use 87077 for tests like the CLO test formerly reported as 87072, since it does not represent accurate coding. Laboratories should discuss this issue with carriers and third-party payers and obtain written direction about how to report this test.
 
"Physicians will sometimes order sensitivity tests on cultures, especially following failed treatment for H. pylori infection," Barrett says. The most common tests for colony susceptibility to antibiotics are the disk method (87184, susceptibility studies, antimicrobial agent; disk method, per plate [12 or fewer agents]) and the MIC method (87186 ... microdilution or agar dilution [minimum inhibitory concentration (MIC) or breakpoint], each multi-antimicrobial, per plate).
 
Gastric biopsy specimens may also be evaluated for the presence of H. pylori using polymerase chain reaction. This service is reported with a code that is not specific for the organism: 87798 (infectious agent detection by nucleic acid [DNA or RNA], not otherwise specified; amplified probe technique, each organism).
 
Histology tests for the gastric biopsy may involve 88305 (level IV - surgical pathology, gross and microscopic examination, stomach, biopsy) or 88312 (special stains [list separately in addition to code for surgical pathology examination]; group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each). Report 88312 only if special stains are carried out. The pathologist might perform a Giemsa or silver stain on the tissue. "Each special stain should be reported with one unit of 88312, which is special stains for microorganisms," Dettwyler says.
 
Because H. pylori is also indicated in the development of gastric cancer, cytopathology smears may be evaluated. "This could be a touch prep (88161, cytopathology smears, any other source; preparation, screening and interpretation) or a smear from a gastric swab or washing (88104, cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation)," Dettwyler says.

Antigen Tests

Noninvasive tests aid in the detection of H. pylori infection based on enzyme methods to detect the antigen. The first code in this category is 87338 (infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Helicobactor pylori, stool). This was a new code in CPT 2000 and describes a noninvasive, commonly used test for the diagnosis and treatment for H. pylori infection. The second code is 87339 (... Helicobactor pylori). "This code was added in CPT 2001 and describes a test similar to 87338 carried out on a non-stool specimen such as a gastric washing," Dettwyler says.

Urea Breath Tests

"Breath tests represent another noninvasive avenue for diagnosing and following up treatment of H. pylori infection," Dettwyler says. There are two sets of codes for these tests based on the ion of carbon used and the detection method.
 
In both tests, the patient ingests a urea capsule. For one test the urea contains heavy carbon (C-13), and for the other test the urea contains radioactive carbon (C-14). In the presence of urease produced by the H. pylori organism in the stomach, the labeled urea will break down into CO2 that is absorbed into the blood, then exhaled. One test measures the presence of C-13 in the breath using a mass spectrometer, and the other measures the presence of C-14 in the breath using a liquid scintillation counter.
 
Both tests are represented by two codes: one for the administration of the labeled urea and the collection of the breath sample, and the other for the analysis of the breath sample. If the laboratory administers the drug and collects and analyzes the breath sample, two of the following four codes should be reported:
 

83013 Helicobactor pylori; analysis for urease activity (mass spectrometry) (This code describes the C-13 test)
 

83014 Helicobactor pylori; drug administration and sample collection or

78267 urea breath test, C-14; acquisition for analysis
 

78268 urea breath test, C-14; analysis.
 
Dettwyler says this test is normally performed in an imaging facility rather than a clinical laboratory.
 
Although H. pylori tests require very different methods and specimen sources, they all identify the presence of the same organism. For this reason, carriers and third-party payers may restrict payment for many of these codes when billed together for the same patient. For example, CCI edits prohibit reporting two variations of the urea breath test (78267-78268 and 83013-83014) for the same patient on the same day. Because the results of these tests provide comparable data for diagnostic or treatment evaluation, they would not be covered if billed together.
 
Similarly, some carriers restrict the use of the urea breath test in conjunction with evaluation of gastric endoscopy. Many carriers have established LMRPs for the H. pylori codes. Some carriers will not cover the breath test within six weeks of an endoscopy, while others will cover a follow-up breath test or a breath test following endoscopy within four to six weeks of antimicrobial therapy to confirm eradication of H. pylori infection.
 
H. pylori tests are almost universally excluded from coverage for screening purposes. The tests are covered only for patients with signs and symptoms of disease, often including generalized symptoms such as dyspepsia (536.8) or abdominal pain (789.0x). Contact your local carrier or third-party payer for specific coverage rules.