Pathology/Lab Coding Alert

Question: Our physician office lab performed rapid strep and rapid influenza tests that the provider ordered for a patient, but we received a denial when we billed 87880 and 87804 together. What could be the reason for the denial, since there is no CCI edit for these codes?

Illinois Subscriber

Answer: You are correct that there is not a Correct Coding Initiative (CCI) edit for 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza) and 87880 (... Streptococcus, group A).

However, some Medicare contractors and other payers have policies about these codes that restrict how you can use them based on medical necessity.

For instance: At least two payers state, "Patients with streptococcus, group A present uniquely discrete signs and symptoms inconsistent with influenza. Therefore, testing for both is not medically necessary because of the improbability of concurrently contracting influenza and streptococcus."

Also, some payers restrict when they'll pay for influenza testing, denying payment during the seasons when the condition is uncommon. For instance, a Texas payer "will no longer reimburse providers for performing infectious agent antigen detection testing by immunoassay with direct optical observation, influenza tests (procedure code 87804), between the dates of June 1 and August 31of each year," because "the number of positive influenza test results reported by the State of Texas between June 1 and August 31 was extremely rare if not nonexistent."

Bottom line: You need to consider your payer's coverage rules based on medical necessity, not just on the CCI edit restrictions that may impact your billing and reimbursement.