Pulmonology Coding Alert

Question: Our pulmonologist recently performed two tests for influenza A and B using a test sample and differentiating test kit. We reported the procedure with 87804 x 2. We got paid for only one unit of 87804 and the other test was rejected. Are we wrong in our claim for the second test?

Indiana Subscriber

Answer: You are not wrong in your claims for two units of 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; Influenza) as two different and distinct analyses for each influenza type was conducted. However, a majority of the insurance carriers will not pay for the second test indicating that the second test is considered to be duplicative.

However, in order to distinguish the second test as a distinct test, you can append modifier 59 (Distinct procedural service) to the second test. This could be a way out to get paid for both the tests. So, you will report the test with 87804 and 87804-59. But, some insurance carriers might want you to use modifier 91 (Repeat clinical diagnostic lab test) instead of modifier 59 appended to the second test.

The best way to go about this would be to clarify with the payer beforehand to know their policy regarding payments for the second test. If you check with the payer, you will get to know their preference and will avoid denials that could happen if you append the wrong modifier.