Pulmonology Coding Alert

Question: When we report 99291 for in-office critical care in addition to influenza and RSV test, the insurance carrier bundles the labs into the critical care. Does the E/M include the labs?


Oklahoma Subscriber
Answer: The critical care codes do include many CPT codes, but not an influenza or respiratory syncytial virus (RSV) test. You could send the insurer a copy of CPT's critical care services notes that state 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) includes the following codes:

 71010, 71015, 71020 - chest x-rays
 93561-93562 - cardiac output measurements
 94760, 94761, 94762 - pulse oximetry
 99090 - blood gases, and information stored in computers, such as blood pressures, hematologic data, ECGs
 43752, 91105 - gastric intubation
 94656, 94657, 94660, 94662 - ventilation management
 92953 - temporary transcutaneous pacing
36000, 36410, 36415, 36540, 36600 - vascular access procedures. Point out that CPT does not include the tests you performed to determine the patient's illness.

Tip: Double-check that you're using the right RSV code. You should use 87807 (Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus) for RSV Binax NOW, as well as Integrated Biotechnology's RSV test called Integrated Biotechnology Quick Lab.

You should no longer report the test with unlisted-procedure code 87899 (Infectious agent detection by immunoassay with direct optical observation; not otherwise specified). CPT 2005 introduced a specific code for the in-office RSV test.

You may also want to look at the ICD-9 codes you report. If you do not make a definitive diagnosis of influenza (487.x) or RSV (079.6) in the chart, use the patient's signs and symptoms for the test codes. For instance, link the flu test (87804, Infectious agent antigen detection by immunoassay with direct optical observation; influenza) to the patient's chief complaint(s), such as nausea with vomiting (787.01) and/or chills with fever (780.6).

You may also want to ensure that you are reporting the labs correctly. Carriers may deny your claim for reasons other than you realize. 

Medicare guidelines indicate that labs performed in physician offices require a CLIA certificate of waiver. Without this waiver, you cannot report labs provided in-office. And when you obtain the waiver that allows you to provide and bill for specified tests, you must report certain test codes with modifier QW (CLIA-waived test). Both 87804 and 87807 are CLIA-waived and require modifier QW when reporting these services. For more information regarding CLIA regulations, refer to the CMS site http://www.cms.hhs.gov/clia/.