Beware Payer Bundling for Multiple STI NAAT Tests
Know when payer policy overrides CPT®, NCCI rules. Consider the following scenario, common to laboratories across the country: A clinician suspects their patient has a sexually transmitted infection (STI) and orders testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis to try to identify the infectious agent responsible. Your lab performs nucleic acid amplification tests (NAAT) for each of those organisms, which you bill using the following codes: Your office submits a claim for all three tests, only to find the insurance company has bundled all three into 87801 (Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique). You might feel like this is worth appealing, but before you do, read on to find out what is going on, as an appeal won’t help you get full reimbursement for the tests. Even so, you should still keep reporting your NAAT claims for STI testing individually, even though that won’t be the way you’ll get paid. First, Understand the Confusion What makes this scenario difficult from a coding perspective is that payer policy is at odds with CPT® guidelines. One of the notes accompanying 87801 tells you, “for each specific organism nucleic acid detection from a primary source, see 87471-8766[2].” In other words, CPT® tells you to code each NAAT test individually. This is especially important when a clinician orders tests to identify specific organisms, which is the case in this scenario. The test described by 87801 simply results in a positive or negative result for multiple organisms that are not specified; the single, individual organism tests result in positive or negative results for the organism specified in the code descriptor, which is what this clinician wanted in this scenario. CPT® guidelines are also reinforced by advice provided in CPT® Assistant Volume 23, Issue 6 (June 2013), which notes that “if the test results differentiate between Chlamydia trachomatis and Neisseria gonorrhoeae, then it would be appropriate to report codes 87491 … and 8759.” However, “If the results do not differentiate, then it would be appropriate to report code 87801.” Next, Understand Payer Policy Medicare and many private payers enforce their own guidelines, however. Medicare and Medicaid payer Molina Healthcare’s Reimbursement Policy for STI Lab Panel Testing states that “If two or more of the single test codes (87491, 87591, and/or 87661) are billed separately for the same member, by the same provider, and on the same date of service, Molina Healthcare's reimbursement will be calculated based on the rate for procedure code 87801.” That’s because Medicare views 87801 as “more comprehensive as it covers the detection of multiple infectious organisms.” The same policy is also enforced by Anthem BlueCross BlueShield, Blue Cross and Blue Shield of North Carolina, Highmark Blue Cross Blue Shield of Western New York, and many others. Then, Understand the Implications of STI Testing Bundling on Your Bottom Line Unfortunately, when your lab provides STI testing, your lab’s bank account will take a hit. Under the 2025 Clinical Laboratory Fee Schedule (CLFS), the national payment rate for 87801 is $70.20; while the total reimbursement rate for 87491, 87591, 87661 would amount to $105.27 if you were able to bill for them separately, as Medicare values each single organism NAAT at $35.07 per test. This means most payers’ STI testing bundling policies result in a loss to your lab of $35.07 when 87491, 87591, and 87661 are bundled into 87801. Last, Understand Why Your Reporting Shouldn’t Change After seeing all these policies and seeing the reimbursement rate for the tests, you might be tempted to take the easy route and simply report 87801 every time you submit claims for STI testing. But you shouldn’t, and here’s why. When billing any claim, correct coding requires you to use only those codes that exactly describe the work your provider has performed. So, if your lab does perform all three STI tests, that is what you should report, even though your reimbursement from the payer will be calculated on the fee schedule for a completely different code. In fact, this coding advice is echoed in the STI testing policies of some payers, including Blue Cross Blue Shield of Rhode Island and Amerigroup/Wellpoint. Both payers tell you that “the provider is required to bill for the applicable single STI CPT codes, as rendered. The comprehensive CPT code will be reimbursed as indicated.” Important: Both payers also state that modifiers will not override the policy, so there is no legitimate way you can bypass 87801 bundling with those payers. This contradicts National Correct Coding Initiative (NCCI) edit policy, as 87491, 87591, or 87661 are listed as Column 2, or component codes, to 87801 and NCCI assigns all codes with a modifier indicator of “1,” meaning the bundling can be overridden with an NCCI-associated modifier when appropriate. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
