Pediatric Coding Alert

Question: Our payer recently denied payment when we billed 87880 and 87804 for the same visit. We ran both codes through Correct Coding Initiative (CCI) edits but found no conflict. So, why was the payment denied?

Codify Subscriber

Answer: While you are correct that CPT^® codes 87880 (Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) and 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza) can technically be billed together when administered during the same day, your payer probably denied the payment for two different reasons.

First, streptococcus, group A, and influenza are two illnesses that are incompatible. Or, as health care corporation Centene explains it, "patients with streptococcus, group A present uniquely discrete signs and symptoms inconsistent with influenza. Therefore, testing for both is not medically necessary because of the improbability of concurrently contracting influenza and streptococcus" (Source: https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/FluandStrepTesting.pdf).

Second, 87804 is a rapid influenza test, which, Centene argues, has "inadequate value ... at the beginning and end of the season" and is unnecessary during the peak of influenza season because "once influenza activity is documented in the geographical area, a clinical diagnosis can be made based on symptoms." In this sense, Centene regards 87804 itself as unnecessary, which could provide yet another reason for your payer's position.

So, even though there is no CCI conflict for 87880 and87804, and there are currently no CMS guidelines to indicate the two codes are bundled, denying the payment seems to be down to individual payer preference.