Pathology/Lab Coding Alert

Question: I’m getting denials for 87507 when we run a multiplex nucleic acid panel for 14 gastrointestinal pathogens on a fecal specimen. What could be the problem?

Virginia Subscriber

Answer: Denials for 87507 (Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets) could occur for multiple reasons and may vary depending on your payer.

Organisms: To bill for 87507, you must document the 14 organisms that your test interrogates. The possible gastrointestinal organisms could include Campylobacter, Clostridioides difficile (formerly Clostridium difficile), Plesiomonas shigelloides, Salmonella, Vibrio, Yersinia, E. coli strains such as E coli O15, Shigella, Cryptosporidium, Giardia lamblia, etc.

Diagnosis: As for all procedures, you must have a “payable diagnosis” to bill 87507 that demonstrates medical necessity for the procedure. That means your documentation must support, and your claim must indicate, an ICD-10-CM code that shows the need for the test.

Family problem: Code 87507 is a child code in a family of three codes that differ based on the number of target pathogens interrogated by the test. The other codes in the family include 87505 (… 3-5 targets) and 87506 (… 6-11 targets). Payers may expect different conditions to demonstrate medical necessity for the three codes.

For instance: The Medicare contractor CGS covers 87505 for immune competent beneficiaries, 87506 for immune competent beneficiaries when one of the targets is Clostridioides difficile for a patient with a clinical concern for colitis caused by that organism, and 87507 only for critically ill or immunosuppressed patients. CGS also specifies the expectation that a patient needing the 87507 test will be an inpatient, and CGS will only consider coverage for Part A claims.

Bottom line: In addition to clearly documenting details of your test and the organisms tested, you need to document medical necessity and follow payer coverage rules to get reimbursement for your lab’s work.