Pathology/Lab Coding Alert

Question: We received a denial for 86255 stating that we needed to provide documentation of the test that includes the description and FDA status. The denial states that they need the information for them to support payment for the code with the diagnosis we submitted: epigastric pain and early satiety. Where could I find this information, including what diagnoses make 86255 payable?

Codify Subscriber

Answer: You should use 86255 (Fluorescent noninfectious agent antibody; screen, each antibody) when the lab performs a fluorescent antibody test for a noninfectious agent, but CPT^® does not provide a more specific code for that antibody. Your payer is asking for documentation about what specific antibody(ies) you’re testing.

Your lab should be able to tell you what antibody the test was for. Without that information, it’s difficult to completely answer your question, but based on some other information you provided, we can make some assumptions that might help.

You mention that the diagnosis was epigastric pain and early satiety. Assuming that these symptoms encouraged the ordering physician to request lab tests to aid in the diagnosis of gluten sensitivity and celiac disease, perhaps the 86255 describes a test for endomysial antibody (EMA) IgA, which is a fluorescent test for an auto-immune (noninfectious agent) antibody that has a high specificity for celiac disease and does not have a specific CPT^® code.

If that’s the case, the lab would typically first perform a Tissue Transglutaminase (tTG) screen, because anti-tTG antibodies can indicate an immune response to gluten. If the tTG screen is positive, the lab commonly reflexes to an EMA IgA test, which you should code as 86255.

You also asked what diagnosis codes would be “payable” for this test. First, remember that you must code lab tests with the diagnosis provided by the ordering physician. You should not “code for payment” by selecting a diagnosis code that is payable. In this case, the diagnosis codes are R10.13 (Epigastric pain) and R68.81 (Early satiety). Also regarding your question, the FDA does not provide a list of payable diagnoses for FDA-approved tests. Payers may provide such lists through coverage determination documents.

Finally, you asked about FDA approval of the test. You can go to the following website to look up a specific lab test to see if it has FDA approval: www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/LabTest/ucm126079.htm.