Pathology/Lab Coding Alert

Question: We routinely test post-transplant patients for BK virus by PCR (87798) and quantify EBV (87799) to identify active infection. We-re getting denials when we bill both codes together. These are two different organisms, so what is the reason for denials, and how do we stop them?


Missouri Subscriber


Answer: Unlike many infectious agent codes, the codes you-re billing are not for a specific organism:

- 87798--Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism

- 87799--- quantification, each organism. You are correct to use these -not otherwise specified- codes because CPT does not list specific nucleic acid codes for the organisms you-re investigating--Epstein-Bar virus (EBV) and BK virus. Both of these organisms can involve post-transplant complications.

Bill for each organism: Although the code definitions state that you should use the code for -each organism,- your payer may not know that you are reporting the codes for two separate viruses. Because the Correct Coding Initiative (CCI) bundles 87798 and 87799 as a mutually exclusive code pair, Medicare and other payers may deny the claims.

Do this: The CCI edits list the 87798-87799 code pair with a modifier indicator of -1,- which means that you can override the edit pair when appropriate. Because you-re using the tests for two different organisms, you should use modifier 59 (Distinct procedural service). According to CMS instruction, you should append modifier 59 to the lesser-valued code (87798).

Be sure your documentation backs up your claim. Your records should show the physician order and test results for BK virus and EBV to justify the use of modifier 59 to override the edit pair.