Pediatric Coding Alert

Pediatricians perform many "lab" tests in the office such as rapid tests to denote whether the patient has strep throat, influenza or mononucleosis. Because of technological advances resulting in a proliferation of new tests and some new codes, pediatricians may not know which code to use. Below are common "waived" tests in-office tests that under the Clinical Laboratory Improvement Act (CLIA) may be performed without a high-level certification and their correct codes.
 
Waived status: Consider your CLIA status when selecting a test code: If, like most pediatricians, you have only waived status, do not use any code that requires a higher-level certification. Some physicians may want to use a test that is clinically appealing, and therefore the practice opts to have a moderate-complexity certification, which requires a big financial investment, explains Joan Gilhooly, CPC, CHCC, a coding and reimbursement consultant based in Deer Park, Ill. "But most pediatric groups have waived status," she says. When filing with Medicare, use modifier -QW (CLIA waived test) to indicate that a test is waived.
 
Note: We do not endorse any of the tests referenced in this article, but cite them for identification purposes for our readers' convenience.

Urinalysis: For urine screening for a variety of conditions, including diabetes, urinary tract infections, dehydration and jaundice, use 81002 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy). Bill 81003 ( automated, without microscopy) for the Bayer Clinitek 50 Urine Chemistry Analyzer, the Chemstrip Mini UA from Boehringer Mannheim, the Roche Diagnostics/Boehringer Mannheim Chemstrip 101 Urine Analyzer, Teco Diagnostics URITEK TC-101 Urine Strip Reader. Use CPT 81007 (Urinalysis; bacteriuria screen, except by culture or dipstick) for the Diatech Diagnostics Uri screen that is approved for OTC use and detects catalase that is associated with urinary tract infections. There are two codes for the Bayer Multistick Pro reagent strips: 81002 and 82570 (Creatinine; other source). These two Bayer test systems have been added recently to the list of waived tests.
 
Rapid strep test: Use 87880 (Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A) for the tests that rapidly test group A streptococcal antigen from throat swabs: the Abbott Signify Strep A Test, the Applied Biotech SureStep Strep A (II), Beckman Coulter Primary Care Diagnostics ICON FX Strep A Immunochemical Strep A Test, Becton Dickinson LINK 2 Strep A Rapid Test, Binax NOW Strep A Test, BioStar Acceava Step A Test, Genzyme Contrast Strep A, Fisher HealthCare Sure-Vue Strep A, Jant Pharmacal AccuStrip Strep A (II), LifeSign LLC Status Strep A, Mainline Confirms Strep A Dots Test, Meridian Diagnostics ImmunoCard STAT Strep A from Applied Biotech, Polymedco Inc. Poly Stat A (II), QuickVue Dipstick Strep A, Quidel Quick Vue In-Line One-Step Strep A Test, Remel RIM A.R.C. Strep A Test, SmithKline ICON Fx Strep A Test, the Wyntek Diagnostics OSOM Strep A Test, and Wyntek OSOM Ultra Strep A Test.
 
Flu test: Use new code 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza) for the new quick test for qualitative detection of influenza Type A and B from nasal swab, nasal wash, or nasal aspirate; use this code for Quidel QuickVue Influenza Test. It is no longer necessary to use unlisted-procedure code 87999 (Unlisted microbiology procedure) for the QuickVue Influenza Test. This test was added to the waived list in December 2001 on an "emergency basis," says Kathy Todd, who works on CLIA issues for the CMS Division of Laboratories and Acute Care Services in Baltimore. Code 87449 (Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, not otherwise specified, each organism) is for the ZymeTx Zstatflu Test. Do not use 87804 for the Zyme flu test.
 
Mononucleosis: Use 86308 (Heterophile antibodies; screening), a qualitative screening test for the presence of heterophile antibodies that helps diagnose mononucleosis, for Applied Biotech SureStep Mono Test, BioStar Acceava Mono Test, the Genzyme Contrast Mono (whole blood), the Jant Accutest Infectious Mononucleosis Test, LifeSign UniStep Mono Test, Meridian ImmunoCard STAT Mono, Quidel Quick Vue Plus Mono (formerly called Quidel Cards O.S. Mono), Remel RIM A.R.C. Mono Test, Seradyn Color Q Mono from Genzyme Diagnostics, the Wampole Mono-Plus WB, the Wyntek Diagnostics OSOM Mono Test (whole blood), and Wyntek Signify Mono Test.

Rapid strep tests are more useful than other rapid tests because the results affect treatment, says Charles Scott, MD, FAAP, who practices with Medford Pediatric and Adolescent Medicine of Medford, N.J. "It's nice to do in-office mono or flu tests, but the results don't affect your treatment," he says. Also, managed care companies will often not pay for in-office tests because they have contracted with labs for tests. Physicians often perform the strep tests for clinical benefits but don't get paid for them.

Pregnancy: Report some of these urine tests that diagnose pregnancy with 81025 (Urine pregnancy test, by visual color comparison methods); use 84703 (Gonadotropin, chorionic [hCG]; qualitative) for the Bayer Clinitek 50 Urine
Chemistry Analyzer.
 
For other tests that are performed using a specific device, such as a glucometer for a glucose test, bill 82962 (Glucose, blood by glucose monitoring device[s] cleared by the FDA specifically for home use).
 
Other waived tests performed by pediatricians include 82010 (Acetone or other ketone bodies, serum; quantitative) for the PTS Bioscanner for blood ketones; 82044 (Albumin; urine, microalbumin, semiquantitative [e.g., reagent strip assay]) for renal disease; 83026 (Hemoglobin; by copper sulfate method, non-automated), 85013 (Blood count; spun microhematocrit) and 85018 (Blood count; hemoglobin) for anemia; and 83036 (Hemoglobin; glycated) for hemoglobin A1C, such as the Bayer DCS 2000.

If a test is so new that no CPT code exists for it, code based on the type of test, Gilhooly says. Use the unlisted-procedure code that is appropriate for the type of test performed the pathology section of CPT contains multiple unlisted-procedure codes. For waived status alone, only use unlisted-procedure codes that apply to waived tests.
 
To set a price for an unlisted pathology code, look at a similar code in CPT and choose a price accordingly. The price also depends on how long it takes to run the controls, Gilhooly says. For example, if the test is performed on 10 patients separately with a control run each time, the price should be higher than if the tests are performed at the same time (i.e., the end of the day) with only one control.

Specimen handling: Although it is ethical to bill 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) for expenses related to specimen processing, it should only be used for above-normal costs, Gilhooly says.
 
For example, a pediatrician needs to test blood on a stat basis. The patient is vomiting and dehydrated, and the doctor wants to check the electrolytes. The lab charges him for a stat pickup and sends a report in one and a half hours and bills the practice for these services. Report 99000, with a primary diagnosis of 009.1 (Ill-defined intestinal infections; colitis, enteritis, and gastroenteritis of presumed infectious origin) and a secondary diagnosis of dehydration (276.5, Volume depletion).
 
In another example, an esoteric test, such as specific viral cultures, needs to be performed. The specimen must be frozen and sent to a special lab by Federal Express, which will cost extra; bill 99000 to the plan.
 
Specimen collection: "Code 99000 is only for preparing a specimen to send it out to a reference lab," Gilhooly says. It has nothing to do with specimen collection. Code for collection with the appropriate venipuncture (36410*, 36415*) or catheterization (53670*) codes. For pap smears, use 99000.
 
Note: Be cautious when using a manufacturer's recommendation for a code. They have a sales incentive, no expertise in CPT coding, and don't run their recommendations past the AMA. Some are more sophisticated than others and have certified coders as consultants. Regardless, check the code with a reference lab or a pathologist rather than with a manufacturer.