Pathology/Lab Coding Alert

Question: Our lab is getting denials for testing for GI pathogens such as one of the 87505 family codes. What could be the reason for the denials?

Codify Subscriber

Answer: Many insurers have coverage policies for 87505 (Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets), 87506 (… 6-11 targets), and 87507 (… 12-25 targets), so you should start by looking at coverage rules specific to your carrier.

For instance, Medicare Administrative Contractor (MAC) National Government Services, Inc. (NGS) provides a list of diagnosis codes that demonstrate medical necessity for the test. These include many infectious conditions such as A04.9 (Bacterial intestinal infection, unspecified), immune conditions, such as B20 (Human immunodeficiency virus [HIV] disease), chronic intestinal disorders such as K50.919 (Crohn’s disease, unspecified, with unspecified complications), or transplant-related conditions.

POS: Another critical factor for 87505-87507 test coverage is place of service. NGS local coverage states that the codes “must be billed in POS 20, 21, 22, 23, or 81 (Urgent Care, Inpatient Hospital, Outpatient Hospital (observation), or Emergency Room), or in POS 81 (Independent Laboratory) in the case of a pre-transplant evaluation for an immune-compromised beneficiary.”

Ordering physician: NGS also specifies that the 87505-87507 tests be ordered by a clinical specialist in an area such as infectious disease, gastroenterology, oncology, or transplant.

Bottom line: Look to your payers’ coverage rules for these tests to ensure that you’re billing within the covered parameters and acquire a signed advance beneficiary notice (ABN) if not.