Wiki BCBS Flu Code 87804 Denial

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AMELIAHERRERA

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I just recently began to receive denials from BCBS on these codes stating "Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed". They have been paying all along until this month. This is how we've been billing them: 87804, 87804-59. I have searched and researched and have not been able to find any updates for BCBS. Is anyone else getting denials? How do you bill for these codes? Thanks.
 
We are having the same issue. We have found updates but the policy is extremely vague. Here is the BCBS of TX policy. https://www.bcbstx.com/docs/provide.../lab-mgmt/cpcplab033-dx-test-flu-01012025.pdf

I believe the 87804 are bundling into each other. They are essentially saying in the policy they are only going to pay for 1 test. But they are two separate tests for Flu A and Flu B, so it's not making a lot of sense. That goes against CMS as well. So I am not sure at current but researching.
 
We are experiencing the same issue. We have submitted it as 87804, 87804-59 and also as 87804-59 x2. Both methods have produced the same bundling denial.
 
I started researching this topic today. When testing a patient for influenza A & B using one swab and one test, are we supposed to report 87804 and 87804-59 or an unlisted code 87899? CPT Assistant Special Edition/October Update / Volume 30 - 2020 indicates "even if a lab procedure produces multiple reportable test results, only a single CPT code may be reported for the procedure. If there is no CPT code that describes the procedure, the lab should report an unlisted procedure code with a single unit of service." Any thoughts?
 
Our clinic is facing the same issue with 87804, our denial- the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
we billed 87804, 87804 59, 99214 25, 87811, J0696, and 96732
 
AMELIAHERRERA said:
I just had a few claims that paid on both 87804 and 87804-59. The few claims that paid had one of the symptoms as a primary diagnosis on the claim and labs that were on this list. https://www.bcbstx.com/docs/provide.../lab-mgmt/cpcplab033-dx-test-flu-01012025.pdf I sent a couple corrected claims today and will let you know what the outcome is as soon as I get something back
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So should these CPTs be tied to the primary diagnosis such as fever or sore throat as stated on this BCBS disclaimer? Have you had progress with your other claims being filed the way that you mentioned?
 
Hello, yes were are getting these codes denied as bundled. Specially with BCBS Advantage plans. For the most part once there is a medical diagnosis I don't bill the symptoms and they were paying just fine, until recently. Im submitting them as 2 units vs 2 lines.
 
AMELIAHERRERA said:
I just had a few claims that paid on both 87804 and 87804-59. The few claims that paid had one of the symptoms as a primary diagnosis on the claim and labs that were on this list. https://www.bcbstx.com/docs/provide.../lab-mgmt/cpcplab033-dx-test-flu-01012025.pdf I sent a couple corrected claims today and will let you know what the outcome is as soon as I get something back.
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From the BCBS document, it appears that they will only reimburse if the patient has fever/chills AND another one or more of the listed symptoms. I don't bill symptoms if there is a medical diagnosis, but I have submitted corrected claims listing fever and other symptoms patient had in hopes for payment. They have even denied when influenza is the only diagnosis listed.
 
We are having the same issue too. We bill 87804 with 2 units billing the symptoms of cough, fever, etc. BCBS is randomly paying some and denying others. We’ve tried calling to have the denied claims sent back but they can’t due to the Availity denial code referring to the BCBS policy effective 1.1.25. We’ve tried billing one unit and these are denying as well. I’ve sent a couple claim review forms in for a second review but haven’t received a response yet. I guess I will try appealing a few claims as well. It makes no sense why they pay some and deny others when they are billed the same way.
 
dpigamd said:
So should these CPTs be tied to the primary diagnosis such as fever or sore throat as stated on this BCBS disclaimer? Have you had progress with your other claims being filed the way that you mentioned?
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Unfortunately, the corrected claims I sent were also denied, however, I continue to get some that are getting paid and many more that are not. I am billing them the same way.
 
We are getting the same rejection also--but only when we bill the 87804 with a COVID test (87811). For our flu tests we are billing 87804 as 2 units on one line and most insurances are paying like this. Is there any document or policy stating 87804 cannot be billed with 87811 or is mutually exclusive when billed with 87811? We also have rejections will billing the strep test with 87811. Rejections states "mutually exclusive" insurance will pay 87811 but deny other lab tests.
 
I reached out to our regional provider rep and she finally responded. She said that BCBS TX has incorrectly denied claims after the new policy went into effect on 1/1/25. There is supposed to be a fix this week for future claims and they will run a report for denied claims. BCBS TX will reimburse 87804 if it meets the criteria of the policy.
 
corihampton15@gmail.com said:
I reached out to our regional provider rep and she finally responded. She said that BCBS TX has incorrectly denied claims after the new policy went into effect on 1/1/25. There is supposed to be a fix this week for future claims and they will run a report for denied claims. BCBS TX will reimburse 87804 if it meets the criteria of the policy.
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This is wonderful news. I just checked status on my dates of service for 2/19/25 and 2/20/25 and they all have processed for payment. No denials. I tried reaching out to my rep also and she didn't seem interested in helping me out. Lol.
 
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