Pathology/Lab Coding Alert

Look for payers ‘bundling’ payment.

If you’ve wondered why you’re getting denials, or at least “underpayment” when you report multiple sexually transmitted infection (STI) infectious agent nucleic acid amplification test (NAAT) codes, we may have the answer.

“Multiple payers are incorrectly bundling certain individual infectious agent codes to pay for the service at the lower rate of 87801 [Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique],” explains William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Oregon.

Understand Correct Infectious Agent Coding

When your lab performs multiple individual tests, each for a specific infectious agent with an individual result, you should code each test individually. That’s true whether the test method is immunofluorescent technique (87260-87299, Infectious agent antigen detection by immunofluorescent technique …), immunoassay (87301-87449, 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 …), or by nucleic acid probe (many codes in the range 87471-87798, Infectious agent detection by nucleic acid (DNA or RNA) …).

Example: If a clinician suspects that a patient has a STI and orders testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis to try to identify the infectious agent involved, your lab may perform tests for each of those organisms using a NAAT test.

Correct coding: You should report that service using the following three codes:

• 87491 (Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique)
• 87591 (… Neisseria gonorrhoeae, amplified probe technique)
• 87661 (… Trichomonas vaginalis, amplified probe technique)

Incorrect coding: Although CPT^® provides a code for multiple organism testing by amplified probe technique (87801, Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique), you should not report that code in this scenario.

Here’s why: Code 87801 describes a single test for multiple organisms that reports a single result. So, if the lab performed an 87801 procedure for the three relevant STI organisms in question, the result would be positive or negative, without identifying which organism(s) were present. That’s not what the clinician ordered, nor what the lab performed.

This understanding of the code is borne out by a CPT^® text note following 87801, which states, “For detection of multiple infectious agents… which report a single result, see… 87801.”

See individual: Another CPT^® text note following 87801 states, “For each specific organism nucleic acid detection from a primary source, see 87471-8766[2],” which is the code range that includes the three individual codes for the STI organisms in the example.

See What Some Payers Are Doing

Despite the unambiguous instructions described above, some payers are instituting a policy that bundles two or three STI infectious agent NAAT codes into 87801.

“One lab I work with shared the following policy statement from their carrier,” Dettwyler says:

“Anthem considers sexually transmitted infection (STI) testing, CPT^® codes 87491, 87591, and 87661, to be part of a laboratory panel grouping unless provider, state, or federal contracts and / or reimbursements indicate otherwise. When the Plan receives a claim with two or more single test laboratory procedures procedure codes reported, the Plan will bundle those two or more single tests into the comprehensive laboratory procedure code 87801.”

Correct coding: The lab should not report a code that does not describe the work performed. As if to acknowledge that fact, the same payer policy goes on to state, “The provider is required to bill for the applicable single STI CPT^® codes, as rendered. The comprehensive CPT^® code will be reimbursed at indicated above. Modifiers will not override this new policy.”

False: “The term ‘comprehensive’ is a figment of the payer’s imagination, as CPT^® lists no such term for code 87801,” Dettwyler says.

Payment implications: Medicare pays $70.20 for 87801 on the Clinical Laboratory Fee Schedule (CLFS) (2023 national payment amount). The same fee schedule lists $35.09 for each of the three individual STI NAATs, which means a total payment of $105.27.

This STI policy is also at odds with CLFS payment for newer panel codes that provide a result for each organism, such as 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). The CLFS payment for this code is $142.63, which is approximately the equivalent of paying for identification of four infectious agents at the rate of $35.09 for a single organism NAAT.

More payers: Several other payers have instituted a similar policy, such as BlueCross BlueShield Minnesota, Empire BlueCross BlueShield, and Amerigroup Medicare Advantage (based on policy documents available online August 2023).

Consider Impact and Act

When clinicians order a test for the presence or absence of each of the three infectious agents, they expect a report for each organism. If labs were to tell clinicians that they can only perform the 87801 tests because that’s all they’ll get paid for, clinicians would not be happy to receive only a positive or negative result with no identification of a specific infectious agent.

If labs were to do that, payers would effectively be dictating medical practice. If labs don’t do that, they’ll lose pay that they deserve based on sound coding practices.

That’s why “labs need to get clinicians to join them in confronting this payer takeover of the practice of medicine, by protesting these policies,” Dettwyler says.