CLIA License Key:
Update on Rapid Strep Test Coding
Published on Sat May 01, 1999
In the February issue of PCA, we discussed coding for rapid strep tests. The AMA had recently announced (in the December 1998 issue of the CPT Assistant) that 87880 should be used for all immunologically based commercial Streptococcus Group A testing kits whose interpretation relies on a visual reaction observed by the naked eye. We quoted the AMA and the CPT-4 advisor for the American Society of Clinical Pathologists on the use of this code; both said that 87880 is for all group A strep tests which require direct optical observation.
Several weeks after the article ran, we began receiving phone calls from subscribers who said that the code wasnt being recognized or reimbursed by insurance companies, even though they were indeed performing a test that required direct visual observation. After talking to a highly placed source at the Health Care Financing Administration (HCFA), as well as a lab inspector and several pediatricians, we have learned that the AMA and HCFA are in conflict over this code.
CLIA Level Key
The problem is that 87880 is not a waived code, in terms of the Clinical Laboratory Improvement Act (CLIA). In other words, if you do not have a CLIA license to perform moderately complex tests, payersespecially Medicaid, which is HCFAare going to reject a claim for 87880. This is in spite of the fact that the AMA directs you to use this code for rapid strep A testing.
While 87880 is the most definitive code, our HCFA source concedes, the waived strep code (86588-QW) was established as the proper code for waived tests before 87880 came into existence. Insurance companies are beginning to compile information on what kind of CLIA license physicians have, and can deny codes based on the type of license. So, if you dont have a moderately complex CLIA license, and youre using 87880, it will probably get rejected. The QW modifier ( HCPCS Level II ) is only used for CLIA-waived tests.
All of this is likely to change in the near futurethe AMA and the College of American Pathologists will be meeting to discuss changes in the codes for next year. For now, however, you should not use 87880 unless you have a CLIA license to do moderately complex tests. Instead, you should use 86588 (streptococcus, screen, direct) with the QW modifier.
Carrier Determines Payment Not Codes
Remember that whatever the AMA decides, you still need to follow your payer guidelines. It is the responsibility of the payer to decide which code theyll pay, says Noel Doheny, vice president of Boulder, CObased BioStar, which [...]
