Pathology/Lab Coding Alert

Question: Our lab has been using the Cepheid Xpert^® Xpress test using the GeneXpert Infinity system amplified probe technique to identify respiratory targets SARS-CoV-2 and Influenza A and B, and RSV, which we reported as 0241U. Lately we’ve used some kits that have the same targets except they don’t include RSV. Can we still use 0241U?

Michigan Subscriber

Answer: No, you should not bill 0241U (Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected) unless the Xpert^® Xpress test you’re using addresses all listed pathogens.

Code 0241U is a Proprietary Laboratory Analyses (PLA) code, and these codes describe just one specific test by a specific manufacturer or performed by a specific lab.

Cepheid supplies several other kits for respiratory panels using a system such as GeneXpert Infinity, and each of those tests requires different coding depending on the targets.

Specifically, Cepheid provides an Xpert^® Xpress test for SARS-CoV-2 and influenza A and B that does not look for respiratory syncytial virus (RSV), which appears to be the other kits you describe. A different PLA code describes this test, which is 0240U (Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected).

Organism codes: Absent a specific PLA code for the particular combination of respiratory targets, you should turn to CPT^® Category I codes for the specific pathogen, such as 87635 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique) or 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).

High throughput: Recall that instrumentation that processes more than 200 SARS-CoV-2 tests a day are eligible to report the test using U0003 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R). This code pays $75 on the Clinical Laboratory Fee Schedule (CLFS), compared to $51.31 for 87635.