Pathology/Lab Coding Alert

Finding susceptibility studies in a urine culture National Coverage Determination (NCD) makes some coders nervous. When labs test antibiotics on blood cultures, will Medicare subject the codes to urine culture medical-necessity rules?

The answer is no, they shouldn't, says Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders and vice president of ambulatory services, Health Revenue Assurance Associates in Chapel Hill, N.C. "Codes 87184 (Susceptibility studies, antimicrobial agent; disk method, per plate [12 or fewer agents]) and 87186 ( microdilution or agar dilution [minimum inhibitory concentration (MIC) or breakpoint], each multi-antimicrobial, per plate) are not specific to urine," Castillo say. "Labs may use antibiotic susceptibility tests for cultures from blood or other sources."

Because infections produce different signs, symptoms and conditions, editing 87184 and 87186 with the ICD9 Codes for urine culture would result in inappropriate denials for susceptibility tests performed on specimens other than urine.

"Medicare stated in program memorandum AB-02-134 that the bacterial urine culture NCD edit module would not apply to 87184 and 87186. The software would instead return a response of 'not applicable,'and contractors might develop their own edits for these codes," Castillo says. "Unfortunately, Medicare now reports that the editing software did not remove 87184 and 87186 as planned." Although promising an April correction, labs may temporarily see denials for 87184 and 87186 reported to Medicare for conditions requiring cultures from sources other than urine.

"Be ready to appeal these claims, because Medicare's instructions put the onus on the labs to catch the errors," Castillo says. Referring to this problem, program memorandum AB-03-030 states, "Any inappropriate denials should be adjusted when brought to the contractor's attention." The program memo is available on the Internet at http://www.cms.gov/manuals/pm_trans/AB03030.pdf.