Wiki Bordetella Pertussis/Parapertussis PCR - 87798 x 2 vs. 87801?

[sammartin92472]

I have several offices that have billed for this test, Bordetella Pertussis/Parapertussis PCR which is an amplified probe test and they are billing 87801 which is an NOS code as there is no specific code for this particular organism. Our state BCBS has been denying these for records but after doing some research, I'm thinking this is the wrong code for this test altogether. Everything I am finding is that they should be billing 87798 x 2 for this test for the two organisms "each" vs. the 87801 which is for "multiple organisms". Our labs go to Quest Diagnostics and when I pull this test up in their system, they say to bill 87798 x 2 and everywhere else I have looked says 87798 x 2. I have not found anywhere that states to bill 87801 for this test. Looking for some input as to anyone who may know for sure which code should be used for this test? Both Bordetella Pertussis and Bordetella Parapertussis are being resulted on one report and from one nasal swab specimen. Thanks!

 

[karamac]

Bordetella Pertussis/Parapertussis PCR

Couple of questions, is the office performing the test, or are they sending the test to Quest who is performing the test, the provider is pass-thru-billing of that service? If so, your denials may be based on the plan not allowing pass thru billing of laboratory services.

Molecular PCR coding can be a little tricky because of the number of different proprietary assays that are available. Based on your notes, if the test is being performed by Quest and they are telling your to code to 87798x2 then I would default to their recommendation (which I agree with the code but I would need more information on the number of units). Did we confirm that the result was a qualitative or quantitative value?
This is another resource that I use as well- ARUP is a nationally recognized laboratory and I pulled the page related http://ltd.aruplab.com/Tests/Pub/0065080


Your denials may be based not just on the code but the medical necessity of the testing itself. This group of codes saw an incredible jump in utilization since 2014- and payers watch. I know that some plans require a prior auth for some types of PCR testing because they would prefer a less expensive culture be done. These codes and tests while very useful in acute scenarios - are not usually a first line test in the payers eyes. The CDC however does consider Bordetella pertussis/parapertussis by PCR and/or Bordetella pertussis culture as first line options for diagnosis. If your submitting notes, and getting denials, I would dig down into the documentation to ensure that it meets coverage criteria and there are not inconsistencies. Not to sound trite, but if your provider has decided that every person walking in the clinic is getting this -rather than a targeted population of immune suppressed patients, infants >6 months old, or the parents of said infants that are symptomatic-- then this could be an issue. I am not a doctor or provider, but I say this only because I have seen it happen, (way, way too many times) a rep comes in, tells the doctor or provider how great this test is, and then everyone gets the test.

Good Luck!

 

[casseciella]

do you know if code 87798 requires a modifier?

 

[pashirley]

Update to 87798

I have several offices that have billed for this test, Bordetella Pertussis/Parapertussis PCR which is an amplified probe test and they are billing 87801 which is an NOS code as there is no specific code for this particular organism. Our state BCBS has been denying these for records but after doing some research, I'm thinking this is the wrong code for this test altogether. Everything I am finding is that they should be billing 87798 x 2 for this test for the two organisms "each" vs. the 87801 which is for "multiple organisms". Our labs go to Quest Diagnostics and when I pull this test up in their system, they say to bill 87798 x 2 and everywhere else I have looked says 87798 x 2. I have not found anywhere that states to bill 87801 for this test. Looking for some input as to anyone who may know for sure which code should be used for this test? Both Bordetella Pertussis and Bordetella Parapertussis are being resulted on one report and from one nasal swab specimen. Thanks!

Do you have any update to this? Were you able to find out through your BC/BS carrier what there requirements were for this code? Also Which ICD-10 coides are you billing for these services. Just trying to get some feedback if the denials were ever resolved.