Pathology/Lab Coding Alert

Don’t miss separate codes for types.

Flu season isn’t over and may be peaking late, according to the CDC, and that means labs will continue to see orders for flu testing.

Let our experts help you over the hump with this influenza-test primer, complete with strategies to capture all the pay you deserve when testing for more than one strain.

Tip 1: Method Leads Code Choice

Labs use various procedures to evaluate a specimen for influenza infection, and CPT^® provides codes such as the following to capture those services:

• 87400 (Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Influenza, A or B, each)
• 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza)
• 87275 (Infectious agent antigen detection by immunofluorescent technique; influenza B virus)
• 87276 (… influenza A virus)
• 87501 (Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype)
• 87502 (… influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types)
• +87503 (… influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure))
• 86710 (Antibody; influenza virus).

Three broad categories describe the tests. The first includes tests that use an antibody reaction to detect the presence of influenza-virus antigens in the specimen. These include immunoassay tests described by 87400, such as enzyme immunoassay [EIA], that can provide a semi-quantitative measure of the influenza antigen. This category also includes tests that allow labs to qualitatively visualize the antigen/antibody reaction using techniques such as fluorescence tags (87275, 87276) or colorimetric changes (87804).

The second influenza-test category involves antigen detection using nucleic acid probes, which includes codes 87501-+87503. CPT^® also provides codes 87632-87633 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus)…) for assays using this technique that test for a wide range of respiratory viruses, including influenza.

Finally, 86710 describes a test to detect influenza antibody in the specimen, rather than antigens.

POLs: Physician office labs typically perform the 87804 test, according to Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla.

The test yields a qualitative result that the provider can interpret visually via a mechanism such as development of a colored band, explains Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

Code 87804 is a waived-test under the Clinical Laboratory Improvement Amendments (CLIA). That means labs with a certificate of waiver, such as many POLs, can perform the test and report the code with modifier QW (CLIA-waived test). You must use modifier QW when you bill Medicare, but other payers, “may have their own requirements,” says Sarah L. Goodman, MBA, CPC-H, CCP, FCS, president/CEO and principal consultant at SLG, Inc., in Raleigh, N.C.

Tip 2: Know When to Report Multiple Codes or Units

Labs may identify various influenza types and subtypes, and your coding should reflect each individual test. Clinicians commonly order testing for influenza A and B.

CPT^® provides distinct codes for influenza A (87276) and B (87275) testing by immunofluorescent technique that you can separately report.

For a multiple-step immunoassay test, you have just one code (87400) for influenza A and B. The code descriptor states, “Influenza, A or B, each,” indicating that you can report two units of 87400 if your lab tests for each type. Medicare’s Medically Unlikely Edits (MUE) lists a value of two units for 87400, indicating that this coding is appropriate, even if the lab performs just one procedure to achieve individual results for influenza A and B.

Although 87804 doesn’t have comparable language for testing for multiple influenza types, you can report two units of 87804 if the lab performs two distinct procedures to identify the two types. According to the CPT^® manual, you may, “use modifier 59 [Distinct procedural service] when separate results are reported for different species or strains that are described by the same code.”

Caution: The National Correct Coding Initiative Policy Manual gives labs a higher bar, requiring not just distinct test results, but distinct procedures, before you can report multiple units. The manual states that you may “report more than one unit of service (UOS) for testing different strains or species of an organism if and only if different test procedures are performed for the different strains or species. [You] shall not report more UOS than the number of independent test procedures performed.”

That means you can report 87804 and 87804-59 for influenza A and B test results only if the lab documents performing two distinct test procedures, not a single test that gives a result for both influenza A and B.

DNA or RNA: Codes 87501-+87503 describe nucleic-acid detection methods for one or more influenza types or subtypes. Use 87501 for a test that detects just one type, such as influenza A or influenza B. If the test detects two types, such as influenza A and B, you should report 87502. If the assay detects more than two types or subtypes, you should report 87502 for the first two, and +87503 for each additional type or subtype.

Tip 3: Beware CCI Edit Restrictions

Because many of these codes represent different test-methods to detect the same organism, CCI creates procedure-to-procedure (PTP) edit pairs bundling many codes into column 1 and column 2 edits that identify mutually-exclusive procedures. In other words, if your lab performs a test for an organism such as influenza A, don’t report multiple codes for the test, but pick only one code that most accurately describes the method.

Many of these PTP edit pairs have a modifier indicator or “0,” meaning that you cannot override the bundles under any circumstances. These include column 2 code 87804, which you should never report with 87400, 87275, or 87276; and column 2 code 87400, which you should never report with 87276.

Override: Some of the edit pairs have a modifier indicator of “1,” meaning that you can report the two codes together with a modifier such as 59 when your lab performs two separate tests on separate specimens or to identify different organisms.

Example: CCI bundles 87804 as a column 2 code for 87501 with a “1” modifier indicator. That means if the lab performs 87804 to detect influenza A, and the same day performs 87501 to detect influenza B, you may bill for both services. “You can report the bundled codes together using modifier 59 (Distinct procedural service) to override the edit pairs, but only if the lab documents a medically-necessary, distinct procedure,” says William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.