Pathology/Lab Coding Alert

Know how to code for the “Big 3” RSV-related respiratory conditions.

Has your lab been getting a lot of provider orders requesting tests for respiratory syncytial virus (RSV) recently? That should come as no surprise. Last week, the Centers for Disease Control and Prevention (CDC) reported elevated levels of RSV in many areas of the country, resulting in a large rise in hospitalizations of infants under 1 year and children between 1 and 4 years old.

What better time, then, to brush up on your RSV testing and diagnosis coding.

Look All Over CPT^® for RSV Testing Codes

Locating a precise code for RSV infection testing is a continual frustration for coders simply because the codes are not located in one CPT^® group. You’ll find codes for RSV tests in CPT^® Category I listings for antigen tests by many methods, or for an antibody test, as well several proprietary laboratory analysis (PLA) codes. Also, in addition to tests specifically for RSV, many test codes evaluate a sample for multiple organisms, including RSV, simultaneously, which is known as a multiplex test.

Here’s a rundown of the codes you might need to know to select the most appropriate code for the test your lab performs:

RSV-only antigen tests: Based on the lab method used, you have the following codes to choose from:

• 87280 (Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus)
• 87420 (Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; respiratory syncytial virus)
• 87634 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique)
• 87807 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus)

Multiple antigen tests: For tests that look for the presence of multiple pathogens, including RSV, you should look to one of the following codes in Category I:

• 87631 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets)
• 87632 (... 6-11 targets)
• 87633 (... 12-25 targets)
• 87637 (… severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique)​

Antibody test: If a clinician wants to determine if the patient had a prior RSV infection, they may order an antibody test, which you should code as 86756 (Antibody; respiratory syncytial virus).

PLA tests: Several PLA codes also describe tests for multiple respiratory pathogens. The distinction is that these codes describe a single, proprietary test performed by a specific lab or using a specific manufacturer kit.

That means you shouldn’t choose one of the following codes based on the description of the lab method, but you should use the code only if your lab performs the proprietary test below. It also means that if your lab does perform one of the PLA tests, you must use the appropriate PLA code because they take precedence over CPT^® Category I codes:

• 0202U (Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected). Proprietary name: BioFire^® FilmArray^® Respiratory Panel 2.1

• 0223U (Descriptor identical to 0202U). Proprietary name: QIAstat–Dx^® Respiratory SARS CoV–2 Panel
• 0225U (Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected). Proprietary names: ePlex^® Respiratory Pathogen Panel 2, GenMark Dx

Understand Ordering and Definitive Dx RSV Codes

Symptoms: Clinicians may order an RSV test, or a respiratory pathogen panel test, based just on symptoms, such as the following:

• R05.1 (Acute cough)
• R06.02 (Shortness of breath)

Conditions: On the other hand, a physician may have diagnosed a patient with a specific condition, such as an ear infection, and request a lab test to drill down to the infectious agent involved. In that case, the ordering diagnosis may be the condition, such as one of the following:

• H65.- (Nonsuppurative otitis media)
• J06.9 (Acute upper respiratory infection, unspecified)

Definitive Dx: If the lab test returns a positive RSV finding, correct coding requires two codes: B97.4 (Respiratory syncytial virus as the cause of diseases classified elsewhere) and a code for the site of the respiratory infection.

Big 3: The most severe cases of RSV often settle in the lungs or bronchi. When the lab test confirms RSV as the causative agent for these conditions, the physician should report a single, specific ICD-10-CM code, as follows:

• Bronchitis: Code J20.5 (Acute bronchitis due to respiratory syncytial virus) is correct if the physician documents an acute case of bronchitis and a positive RSV test identifies the causative agent. Bronchitis occurs when the main airways in the lungs, known as bronchial tubes, become inflamed and cause the patient to cough. Often the bronchial tubes will fill with mucus, which loosens during a coughing bout.

• Bronchiolitis: Code J21.0 (Acute bronchiolitis due to respiratory syncytial virus) is the best choice when a physician diagnoses a patient with acute bronchiolitis caused by an RSV infection. The condition is common in infants and young children, involving inflammation and congestion of the bronchioles (small airways) of the patient’s lungs.

• Pneumonia: Code J12.1 (Respiratory syncytial virus pneumonia) reports a documented case of pneumonia from RSV, which is one of the most common viral causes of pneumonia in the U.S. Pneumonia is an infection in the lungs, and it is commonly caused by viruses or bacteria.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC