Pathology/Lab Coding Alert

Don't lose out when it comes to Medicare's new urine culture guidelines. Medicare's National Coverage Determination (NCD) clarifies once and for all that you can report together codes for colony count and culture presumptive identification a much-debated question since CPT overhauled the microbiology section.

When CPT 2001 instituted the presumptive and definitive identification paradigm, urine source stood alone with two codes for the initial culture: 87086 (Culture, bacterial; quantitative colony count, urine) and CPT 87088 ( with isolation and presumptive identification of isolates, urine). Coders wondered if they should report both codes when the lab provides a colony count and presumptive identification but has performed only one culture.

"Adding to the confusion came an NCCI [National Correct Coding Initiative] edit for 87086 and 87088 that was later removed, and some local medical review policies (LMRPs) directing labs not to report 87086 and 87088 concurrently," says Larry Small, MS, MT(ASCP), director of compliance and billing services for PCS Laboratory Service Group in Ann Arbor, Mich.

Because it referenced the old codes, the NCD published in the Nov. 23, 2001, Federal Register shed no light on the matter. Now CMS clears all that up with the bacterial urine culture NCD, updated and available on the Internet at http://www.cms.hhs.gov/ncd/searchdisplay.asp?NCD_ID=25&NCD_vrsn_num=2.

"By updating the codes and the coding instructions in the NCD, Medicare clarifies that under some circumstances, coders can report 87086 and 87088 together," Small says.

"The primary bacterial urine culture code is 87086, regardless of the results," Small says. When a physician orders a urine culture, the lab typically performs an initial culture to determine the presence of pathogenic bacteria and estimate the number of organisms present per milliliter of urine. You should report this service as a colony count (87086). Even if the culture is negative, showing no colony growth, you should report 87086 for the initial culture.

If you take that same culture and separately perform other services such as identification and susceptibility studies, you should report those procedures in addition to 87086.

"When the culture is positive and the lab presumptively identifies the organism on the colony count plate, report 87088 in addition to the initial 87086," Small says. You should not report 87088 if the 87086 is negative.

"Presumptive identification uses methods such as colony morphology, Gram stain, and catalase, oxidase, indole or urease tests," Small explains. According to the NCD coding guidelines, "identification based solely on visual observation of the primary media is usually not adequate to justify use of this code."

If the lab identifies multiple organisms from a urine culture, report multiple units of 87088. The NCD states that 87088 "may be used multiple times in association with or independent of 87086, as urinary tract infections may be polymicrobial."

Before performing the culture and colony count, labs should ensure that the physician provides an ICD-9 code listed in the NCD indicating medical necessity for the culture or attempt to get a signed ABN to allow billing the patient for the 87086 service. "But if the initial culture is positive, even without medical-necessity documentation for the 87086 service, Medicare should pay for presumptive identification of the culture (87088) and any subsequent testing such as susceptibility studies," Small says.

Based on the NCD, Medicare should also pay for 87086 and 87088 reported together when labs perform both services on a positive colony count plate. "But because some carriers may deny these codes when reported together based on past NCCI edits or LMRPs, it would be prudent to append modifier -59 (Distinct procedural service) to code 87088 when you report it with 87086," Small says.

"If the lab performs susceptibility studies to help identify possible antibiotics for patient treatment, report that service using a separate code for each isolate tested," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. The bacterial urine culture NCD specifies coverage for 87184 (Susceptibility studies, antimicrobial agent; disk method, per plate [12 or fewer agents]) and 87186 ( microdi-lution or agar dilution [minimum inhibitory concentration (MIC) or breakpoint], each multi-antimicrobial, per plate).

"Report either 87184 or 87186 for the susceptibility test based on the lab method used either disk or MIC," Dettwyler says. The lab typically determines antimicrobial susceptibility based on one method or the other, so you would not ordinarily report these codes together for the same isolate. Medicare's NCCI lists 87184 and 87186 as a mutually exclusive edit pair.

Just as the NCD allows reporting 87088 for each isolate if the culture is polymicrobial, so it allows reporting multiple susceptibility tests when the lab evaluates antimicrobial agents for more than one isolate. Report 87184 or 87186 for each isolate tested.

Although rare for urine cultures, if the lab performs susceptibility studies by methods other than 87184 or 87186, report the appropriate CPT code: 87181 (Susceptibility studies, antimicrobial agent; agar dilution method, per agent [e.g., antibiotic gradient strip]) or 87188 ( macrobroth dilution method, each agent). The correct unit of service for these codes is the number of antibiotics multiplied by the number of isolates.

"If the lab performs further tests for definitive identification of a urine culture isolate, also report the appropriate code for that service," Dettwyler says. The NCD does not address these codes, but you should use them based on microbiology coding principles set forth in CPT. For example, report 87077 (Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate) for additional biochemical panels performed to identify the microorganism to the species level. If the isolate is further typed using methods such as chromatography or immunologic techniques, also report the appropriate code from the 87140-87158 family (Culture, typing ).

The lab may perform cultures for specific organisms not normally recovered by routine aerobic urine culture media, such as anaerobes from suprapubic samples. "You should report those services separately, for example, using 87075 (Culture, bacterial; any source, anaerobic with isolation and presumptive identification of isolates)," Dettwyler says.

The NCD limits the use of these codes as follows: