Pediatric Coding Alert

In the February issue of PCA, we discussed coding for rapid strep tests. The AMA had recently announced (in the December 1998 issue of the CPT Assistant) that 87880 should be used for all immunologically based commercial Streptococcus Group A testing kits whose interpretation relies on a visual reaction observed by the naked eye. We quoted the AMA and the CPT-4 advisor for the American Society of Clinical Pathologists on the use of this code; both said that 87880 is for all group A strep tests which require direct optical observation.

Several weeks after the article ran, we began receiving phone calls from subscribers who said that the code wasnt being recognized or reimbursed by insurance companies, even though they were indeed performing a test that required direct visual observation. After talking to a highly placed source at the Health Care Financing Administration (HCFA), as well as a lab inspector and several pediatricians, we have learned that the AMA and HCFA are in conflict over this code.

CLIA Level Key

The problem is that 87880 is not a waived code, in terms of the Clinical Laboratory Improvement Act (CLIA). In other words, if you do not have a CLIA license to perform moderately complex tests, payersespecially Medicaid, which is HCFAare going to reject a claim for 87880. This is in spite of the fact that the AMA directs you to use this code for rapid strep A testing.

While 87880 is the most definitive code, our HCFA source concedes, the waived strep code (86588-QW) was established as the proper code for waived tests before 87880 came into existence. Insurance companies are beginning to compile information on what kind of CLIA license physicians have, and can deny codes based on the type of license. So, if you dont have a moderately complex CLIA license, and youre using 87880, it will probably get rejected. The QW modifier ( HCPCS Level II ) is only used for CLIA-waived tests.

All of this is likely to change in the near futurethe AMA and the College of American Pathologists will be meeting to discuss changes in the codes for next year. For now, however, you should not use 87880 unless you have a CLIA license to do moderately complex tests. Instead, you should use 86588 (streptococcus, screen, direct) with the QW modifier.

Carrier Determines Payment Not Codes

Remember that whatever the AMA decides, you still need to follow your payer guidelines. It is the responsibility of the payer to decide which code theyll pay, says Noel Doheny, vice president of Boulder, CObased BioStar, which makes strep and other tests. Some carriers say all strep tests have to be coded as cultures. Even if they tell you to use the wrong code, thats the code you have to use in order to get paid. (If an insurance company tells you to use a code that you suspect is wrong, make sure you get the request in writing.)

And the CLIA incongruities dont help. If you have a CLIA license, you know that you get inspected regularly. Rita Scheu is clinical laboratory inspector for laboratory licensing with the Oregon Health Division. As long as the pediatrician uses the waived testand there are 10 for strep group Ahe only needs to get a waived license, Scheu explains. But both the CDC and HCFA say you have to use 86588 for all waived strep tests. And, she adds, you must use the QW modifier on all waived tests. HCFA is being very specific about what codes get used.

Know Your CLIA Levels

Here are some descriptions of the different licenses and where strep tests fit in.

1. Waived level. The first level of a CLIA license is for waived testing onlywaived as in the tests are so simple that CLIA basically waives its regulations, explains Mark Danis, laboratory technical consultant for Rogue Valley Medical Center, an 11-pediatrician ambulatory practice in Medford, OR. These waived tests are simple, and also dont have a direct negative impact on the patient, he says. These would include glucose tests, pregnancy tests, and other tests that can be done at home. Some rapid strep tests are, indeed, waived, he notes. And all of these tests for strep should be coded 86588-QW.

2. PPM level. PPM (provider performed microscopies) are the next level up and are essentially waived, says Danis. Some examples include pinworm preps and KOH preps for fungus.

3. Moderately complex level. These tests are still conducted in physicians offices, but are more complex. The BioStar Optimal ImmunoAssay (Strep A OIA), which is so popular among pediatricians who have labs in their offices, is a moderately complex test. If you have a physician office lab with this level CLIA license, you can use 87880 if you use the BioStar Optimal ImmunoAssay; if you dont have this level CLIA license you cant use 87880or even the test; and if you do have this level CLIA license but you use a waived strep test, you cant use 87880, but instead must use 86588-QW when billing HCFA. This confusion should be resolved by next year; it has taken months for the problem to be understood.

4. Highly complex level. These are the tests which are done in laboratoriesand while some physicians offices have this level of license, the vast majority dont. It is rare for a pediatrician to have it. These are the labs where the culture identifications are donewhere, for example, you send strep cultures and wait several days to find out if it is positive. This is a matter of clinical debate now between pediatricians and managed care plans; some plans wont pay for rapid strep tests done in the office because the culture identification tests are less expensive and, in the eyes of the insurance company, satisfactory. Pediatricians usually prefer the rapid strep test in order to avoid the unnecessary use of antibioticsand also to please the parent, who wants results right away.