Pediatric Coding Alert

Question: We just got denied on a claim billed for strep and influenza A and B test using 87804 QW, 87804 59, QW, and 87880 QW linked to J02.9 and J10.1. The reason given for the denial is not having a valid principal diagnosis. What did we get wrong?

Minnesota Subscriber

Answer: Your coding of the tests in this encounter is correct. Using 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza) to document tests for both influenza A and B strains, and using modifier 59 (Distinct procedural service) to distinguish between them, is permissible, as is using 87880 (Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) to document the strep test. And as the Clinical Laboratory Improvement Amendments (CLIA) program has waived both the influenza and strep tests “as they are so simple that there is little risk of error,” according to the Centers for Medicare and Medicaid Services (CMS), you have also correctly appended modifier QW (CLIA waived test) to each one.

The issue here lies in your choice of diagnosis codes. Simply put, per ICD-10 guidelines, you cannot code J02.9 (Acute pharyngitis, unspecified) and J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations) together. That’s because there is an Excludes1 note for the acute upper respiratory infections (J00-J06) codes that states they cannot be coded in conjunction with the influenza virus with other respiratory manifestations codes (J09.X2, J10.1, J11.1). In other words, the pharyngitis is one of the “other respiratory manifestations” included in the J10.1 diagnosis, so there is no need to code it a second time.