Primary Care Coding Alert

Clear Lab-Test-Trio Reimbursement Hurdles With This Insider Info

Hint: You need more than modifier QW to secure adequate payment

Sales representatives- coding recommendations for expensive CLIA-waived tests sometimes don't pan out, leaving you stuck footing the bill for expensive items like reagent strips. Insiders tell you what they-re doing to ensure snag-free lab charges.
 
-I am having trouble with 86318-QW especially,- says Brenda Phillips at Litchfield Medical Center in Pawleys Island, S.C. Implement this expert advice to make sure you capture CLIA-waived lab charges the first time around.

Overturn 87804-QW Duplicate Denials With 2 Strategies

Coding for last year's release of the influenza B test has dumfounded many family physician coders who report both the A & B test. -The pharmaceutical representatives who sell the products say that you can bill the same code twice for the tests,- says Deb Chandler, BA, CPC, ACS-FP, CCP, with Family Physician Associates in Columbus, Ohio. But her group, which includes more than 150 physicians, started receiving numerous denials for the second 87804-QW (Infectious agent antigen detection by immunoassay with direct optical observation; influenza; CLIA-waived test) as a duplicate of the first.
 
Chandler and the drug reps, however, are right to bill in-office influenza test A & B with two codes. Reason: Influenza test B is a different lab test from influenza test A. Each test detects a different type of influenza antigen -- A and B -- according to Tests Granted Waived Status Under CLIA, which lists Binax's tests use as:
 
- Binax Now Flu Test A -- Qualitative detection of influenza type A antigen in nasal wash and nasopharyngeal swab specimens
 
- Binax Now Flu Test B -- Qualitative detection of influenza type B antigen in nasal wash and nasopharyngeal swab specimens.

Success 1: Today, Chandler's 87804-QW denials are mainly a problem of the past thanks to two strategies:
 
- Attaching modifier 59 (Distinct procedural service) to the second test B code. -We-ve been using modifier 59 to indicate that the second test is separate from the first with pretty good results,- Chandler says.
 
- Creating a form explanation letter. -I took a proactive approach and wrote the insurance company a letter explaining what the two codes are for,- Chandler says. And her effort paid off: -The insurer paid both tests,- she says.

Consult LMRPs to Unlock 86318 Payment

Sometimes a policy, not a modifier, explains a lab test denial. Phillips- payment trouble with 86318-QW (Immunoassay for infectious agent antibody, qualitative or semiquantitative, single-step method [e.g., reagent strip]) sounds like a diagnostic issue, says Annette Grady, CPC, CPC-H, CPC-P, OS, director educational services for Coding Metrix Inc. in North Dakota. Modifier QW became effective on this code April 30, 2006, she says.
 
Most likely, the diagnosis that Phillips is using with 86318-QW doesn't meet the insurer's criteria. -A few states have local medical review policies (LMRPs) that allow a very select number of ICD-9 codes with 86318-QW,- Grady says.
 
Important: The 86318 LMRPs are by carrier, Grady says. -No national medical-necessity policy exists on the lab test code.-
 
Remedy: You have to watch for local coverage items with the h. pylori reagent strip test code. If the coder doesn't use the specific carrier-accepted diagnoses, you won't get paid, Grady says.
 
Some of the ICD-9 codes that will unlock payment for 86318-QW include:
 
- 041.86 -- Other specified bacterial infections; Helicobacter pylori (H. pylori)
 
- 151.0-151.9 -- Malignant neoplasm of stomach.

CMS Green Lights Coumadin, Not Pre-Op PT Diagnoses

Coding for in-office prothrombin time testing (85610-QW, Prothrombin time) can also create another payment hurdle. Most Medicare carriers request that you append modifier QW to indicate that CMS exempts the test from the Clinical Laboratory Improvement Amendments (CLIA) Congress passed in 1988. So if you're receiving denials for 85610, two diagnostic mistakes could be at the root of the problem.  

FPs often order PT testing to check a patient's bleeding rate when a patient is on blood-thinning medication, such as Coumadin. In these cases, experts suggest snag-free claims should contain two diagnoses.
 
To report the primary diagnosis in these situations, you should know your physician's medical reason for giving the test, says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.
 
Often, physicians list V58.61 (Long-term [current] use of anticoagulants). When you use that code as the primary diagnosis, consider including a secondary ICD-9 code to indicate the reason for the use of the anticoagulant, such as 427.31 (Atrial fibrillation).
 
Be sure the diagnoses you-ve listed on the claim form match those your FP documented in the medical record regarding the visit's purpose and the service billed, she says.
 
Be careful: CMS will not pay for PT tests with preoperative examination diagnoses V72.81-V72.85 (Other specified examinations). These five ICD-9 codes indicate that the FP ordered the tests without signs or symptoms. Thus, Medicare considers the tests -screenings- and, therefore, a noncovered service.
  
Out: If, however, the patient has a sign, symptom or past history of disease that indicates an increased surgical risk, Medicare will cover the PT tests, states the national coverage determination (NCD). CMS will reimburse 85610 for several conditions that potentially indicate bleeding problems, such as V15.1 (Personal history of surgery to heart and great vessels).
 
Medicare will also cover the tests if the patient is taking anti-coagulant medication (V58.61, Long-term [current] use of anticoagulants). Keep in mind: CMS is also considering adding 289.81 (Primary hypercoagulable state) as a covered indication for prothrombin time testing.
 
For a list of lab tests, procedure codes, accepted diagnoses, and coverage policies, see -Take the Guesswork Out of Qualifying Tests for PT, H. Pylori and Flu- on page 59.