Pediatric Coding Alert

Question: We often do double flu tests, one for flu A and one for flu B. We bill code 87804 for both, and I have tried to apply modifier 76 to the second one to show that it is not a duplicate. This is coming back as an error stating the modifier is either missing or incorrect. Which other modifier should I use? Or should I bill this scenario another way?

Rhode Island Subscriber

Answer: Per CPT^® Assistant, May 2009; Volume 19: Issue 5, “Code 87804 [Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza] is reported twice because two separate, distinct analyses are performed, providing two separate test results, one for influenza virus A and one for influenza virus B. Certain payers may require the use of modifier 59 [Distinct procedural service] when the same CPT^® code is used; alternatively, the payer may require use of the units box on the claim form.”

So, it looks like you could bill either with a modifier, with units, or list the tests on separate lines depending on payer preference. But you would not use modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) or even modifier 91 (Repeat clinical diagnostic laboratory test) in this case. These modifiers are more commonly used when the first procedure, service, or test was not successful; or when the test needed to be repeated for the purposes of making a definitive diagnosis. Your particular case, where the same test is being used to detect different strains of the flu, does not fit these criteria, and so modifier 59 would be more appropriate if that is the way your payer would like you to bill for the tests.