Pediatric Coding Alert

Question: Is there an age limit associated with a respiratory syncytial virus (RSV) test billed with CPT® code 87807? The test we are using states that it should not be used for children older than 4.

AAPC Forum Participant

Answer: There are no age restrictions listed in either the descriptor for CPT® code 87807 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus) or the general guidelines for the microbiology pathology and laboratory codes (87003-87999).

However, tests billed with 87807 have received a waiver under Clinical Laboratory Improvement Amendments (CLIA). To bill the code, you must perform the test in-house, and your lab must be operating under a CLIA Certificate of Waiver. Per that certificate, “you must follow the manufacturer’s instructions” for each CLIA-waived test, according to the Centers for Medicare & Medicaid Services (CMS) document “How to Obtain a CLIA Certificate of Waiver” found at www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/HowObtainCertificateofWaiver.pdf.

So, if the manufacturer has stipulated that the test should only be given to children in a specific age range, administering this particular test to a child older than 4 could possibly “cause inaccurate results that may result in a misdiagnosis or delay in proper treatment of a patient,” according to CMS. This also means you are “no longer performing a waived test and your laboratory is subject to an inspection and additional CLIA requirements,” CMS goes on to warn.

And don’t forget: As the RSV test is CLIA-waived, you must make sure that you append the modifier QW (CLIA waived test) to the 87807.