Pediatric Coding Alert

Question: Our pediatric office is using 86403 for rapid strep tests and receiving denials for not adding 36415 or 36416. Can I ignore this edit? Should I use 87081 instead?

Alabama Subscriber

Answer: CPT has several strep test codes that you should assign based on the test's methodology.

If your office does a "rapid" strep test, such as Abbott Signify or Binax NOW, to detect the antigen directly from a throat swab, you should report 87880 (Infectious agent detection by immunoassay with direct optical observation; streptococcus, group A). Some insurers want practices to add modifier QW (CLIA waived test) to the code to indicate you have a CLIA-waived certificate, meaning your office is certified to do tests granted waived status under Clinical Laboratory Improvement Amendments (CLIA). For a positive test, link 87880 to 041.01 (Streptococcus; group A). You could link a negative test to 462 (Acute pharyngitis).

You would instead use 87081 (Culture, presumptive, pathogenic organisms, screening only) if your office does the culture, which is commonly used as a back-up to the rapid strep test. If a patient presents with a sore throat and beefy red pharynx, many physicians will order two swabs, one for a rapid strep test and one for a culture, if necessary. If the physician office lab conducts the rapid strep test and the findings are positive, the second swab often is discarded and the culture is not carried out. You would code this as 87880 and the strep diagnosis.

Code 86403 (Particle agglutination; screen, each antibody) is for testing blood and is subject to CLIA edits. That is why you would use 86403 in combination with venipuncture (36415, Collection of venous blood by venipuncture) or a blood draw (36416, Collection of capillary blood specimen [e.g., finger, heel, ear stick]).