Pathology/Lab Coding Alert

Question: Can we bill 87804 and 87502 together? I have added a 59 modifier, but I am still getting denials.

Missouri Subscriber

Answer: Under certain circumstances, you may be able to bill together 87804 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza) and 87502 (Infectious agent detection by nucleic acid (DNA or RNA); 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).

Because each code describes testing for influenza virus using different methods, CMS bundles the codes in the National Correct Coding Initiative (NCCI). The edits list 87804 as a column 2 code for 87502, but allows a modifier to override the edit in appropriate circumstances.

In order to bill for both tests, the medical record must document medical necessity for performing both tests. For instance, if the lab performs a rapid flu test such as 87804, the ordering physician may request a more definitive test to determine types or subtypes, and the lab would subsequently perform an 87502 test.

If the record demonstrates medical necessity for the separate encounter/test, you should be able to bill both codes by appending an appropriate modifier such as 59 (Distinct procedural service) to 87804. You might see denials if you append the modifier to the column 1 code, which is 87502.

Tip: If you’ve had problems with denials, you should contact your payer to determine if they require a different modifier or some other information to pay for both services.