Pathology/Lab Coding Alert

Medical necessity and modifiers spell success Word on the street says denials for three lab tests -- CPT 86318 , 87804 and 85610 -- can plague physician office labs. New coverage rules might leave you holding the bag for these CLIA-waived tests -- unless you follow our insiders- advice to ensure snag-free payment.

-I am having trouble with 86318-QW especially,- says Brenda Phillips at Litchfield Medical Center in Pawley's Island, S.C. Implement this expert advice to make sure you capture CLIA-waived lab charges the first time around. Overturn 87804-QW Duplicate Denials With 2 Strategies Coding for last year's release of the influenza B test has dumfounded many coders who report both the A and B test. -The pharmaceutical representatives who sell the products say that you can bill the same code twice for the tests,- says Deb Chandler, BA, CPC, ACS-FP, CCP, with Family Physician Associates in Columbus, Ohio. But her group, which includes more than 150 physicians, started receiving numerous denials for the second 87804-QW (Infectious agent antigen detection by immunoassay with direct optical observation; influenza; CLIA-waived test) as a duplicate of the first.

Chandler and the drug reps, however, are right to bill influenza test A and B with two codes. Reason: Influenza test B is a different lab test from influenza test A. Each test detects a different type of influenza antigen -- A and B -- according to Tests Granted Waived Status Under CLIA, which lists Binax's tests use as:

- Binax Now Flu Test A -- Qualitative detection of influenza type A antigen in nasal wash and nasopharyngeal swab specimens
- Binax Now Flu Test B -- Qualitative detection of influenza type B antigen in nasal wash and nasopharyngeal swab specimens. Success: Today, Chandler's 87804-QW denials are mainly a problem of the past thanks to two strategies:

1. Attaching modifier 59 (Distinct procedural service) to the second test B code. -We-ve been using modifier 59 to indicate that the second test is separate from the first with pretty good results,- Chandler says.

2. Creating a form explanation letter. -I took a proactive approach and wrote the insurance company a letter explaining what the two codes are for,- Chandler says. And her effort paid off: -The insurer paid both tests,- she says. Consult LMRPs to Unlock 86318 Payment Sometimes a policy, not a modifier, explains a lab test denial. Phillips- payment trouble with 86318-QW (Immunoassay for infectious agent antibody, qualitative or semiquantitative, single-step method [e.g., reagent strip]) sounds like a diagnostic issue, says Annette Grady, CPC, CPC-H, CPC-P, OS, director of educational services for Coding Metrix Inc. in North Dakota. Modifier QW (CLIA waived test) became effective on this code April 30, she says.

Most likely, the diagnosis that Phillips is using with [...]