Wiki Help with respiratory labs

Create Wiki
S

SarahSee1114

Networker
Messages
39
Location
Blue Springs, MO
Best answers
0
I'm struggling trying to learn lab coding. I haven't found anyplace to learn, no AAPC resources or local chapter help has been available so I'm trying to educate myself. Everything I've seen states to just match up the test to the code, which doesn't seem to be very real world situation. I'm working appeals so I'm seeing documentation and claims on the back end.

Please help me understand how the following list of respiratory labs are coded by 4 codes. I understand 87633 is for 12-25 targets, but I don't know which ones. And I also found that these tests were performed by QiStat Respiratory SARS-CoV2 panel and should be billed by 0223U. Is it subjective whether four CPT codes are billed vs. the PLA lab code? Any help at all is appreciated!
Codes: 87486, 87581, 87633, 87798

Adenovirus DNA
Coronavirus_229E (not Covid 19)
Coronavirus_NL63
Coronavirus_HKU1
Coronavirus_OC43
Human Metapneumovirus
Human Rhinovirus/Enterovirus
Influenza A H3
Influenza A H1
Influenza A H1N1/pdm09
Parainfluenza 1
Parainfluenza 2
Influenza A
Influenza B
Parainfluenza 3
Parainfluenza 4
Respiratory Syncytial Virus
Bordetella Pertussis
Chlamydophila pneumoniae - 87486
Mycoplasma pneumoniae - 87581
Covid 19(SARS-CoV2-2)
 
Hello Sara,

I know you posted this a couple years ago, but maybe it will help someone. Laboratory billing can be very complicated. There is a lot of misinformation out there. Make sure you are reviewing the payer specific polices. The best resource i have found is Medicare and Medicaid NCCI edit Manuals Chapter 10. In the introduction section it states:
"If a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT
code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single
unit of service."
This being said, if they are billing 4 codes for 1 test then that is considered unbundling. Since a PLA code has been created for this specific test, that is what should be billed.

Medicaid NCCI Policy Manual | CMS

Medicare NCCI Policy Manual | CMS

www.cms.gov www.cms.gov
 
srgarrick said:
Hello Sara,

I know you posted this a couple years ago, but maybe it will help someone. Laboratory billing can be very complicated. There is a lot of misinformation out there. Make sure you are reviewing the payer specific polices. The best resource i have found is Medicare and Medicaid NCCI edit Manuals Chapter 10. In the introduction section it states:
"If a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT
code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the
procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single
unit of service."
This being said, if they are billing 4 codes for 1 test then that is considered unbundling. Since a PLA code has been created for this specific test, that is what should be billed.

Medicaid NCCI Policy Manual | CMS

Medicare NCCI Policy Manual | CMS

www.cms.gov www.cms.gov
Click to expand...
Stephanie, can you answer these questions for me? I'm new to auditing lab.
When reporting 87631-87633, do Parainfluenza’s 1-4 get counted separately as four targets or are they counted together as one target?

When reporting 87631-87633, do coronaviruses 229E, OC43, NL63, HKU1 get counted separately as four targets or are they counted together as one target?

When reporting 87631-87633, do RSV viruses A & B get counted separately as 2 targets or are they counted together as one target?

Can an RN sign an order for a midlevel provider?
Thanks in advance!
 
Does anyone have an issue with code 87798 from BCBS TX starting this year? We are not getting paid for this code. What is the alternate code we can use in place of 87798?
 
omg I am so happy to have found this. I work in a lab in NJ but receive specimens from all over the country. We are having massive issues with this exact respiratory test along with diarrhea pathogen panel testing (3-5, 6-11 and 12-25 targets) reflex with genotypic resistance. We are receiving denials mainly united and humana stating a more specific CPT code should be used. I researched and per Medicare (as well as the DEX registry) we should be using 87999 but still being denied. We are all pulling our hair out of our head because we are following all coding guidelines and policies. We not know what else to do. It is not a diagnosis code issue. We submitted medical records as well as reconsideration/appeal and this is the response:

1747238327695.png
This is what our requisition/lab order looks like that we submitted as medical records (I blacked out the name of my laboratory):
1747238740636.png1747239091016.png
 

Attachments

  • 1747238814228.png
    1747238814228.png
    92 KB · Views: 4
  • 1747239022371.png
    1747239022371.png
    92.5 KB · Views: 3
Hi Tara, based on report you posted, I would Code as follows:
87631 X 1 for Virus panel (Up to 5 target)
87486 X 1 for Chlamydia pneumoniae
87581 X 1 for Mycoplasma Pneumoniae
87798 X 1 for Bordetella pertussis
87798 X 1 XU for Bordetella Para pertussis
87541 X1 for Legionella Pneumoniae.
Some payers would pay 87798 X 2 all in one line such as Medicare, and some require the code in separate line with description of each bacterium detected.
 
Last edited:
Tara0513 said:
omg I am so happy to have found this. I work in a lab in NJ but receive specimens from all over the country. We are having massive issues with this exact respiratory test along with diarrhea pathogen panel testing (3-5, 6-11 and 12-25 targets) reflex with genotypic resistance. We are receiving denials mainly united and humana stating a more specific CPT code should be used. I researched and per Medicare (as well as the DEX registry) we should be using 87999 but still being denied. We are all pulling our hair out of our head because we are following all coding guidelines and policies. We not know what else to do. It is not a diagnosis code issue. We submitted medical records as well as reconsideration/appeal and this is the response:

View attachment 7952
This is what our requisition/lab order looks like that we submitted as medical records (I blacked out the name of my laboratory):
View attachment 7953View attachment 7956
Click to expand...
I do replied to your message earlier on the main post and then realized you will not get the notification, so replying to your post again:
"Hi Tara, based on report you posted, I would Code as follows:
87631 X 1 for Virus panel (Up to 5 target)
87486 X 1 for Chlamydia pneumoniae
87581 X 1 for Mycoplasma Pneumoniae
87798 X 1 for Bordetella pertussis
87798 X 1 XU for Bordetella Para pertussis
87541 X1 for Legionella Pneumoniae.
Some payers would pay 87798 X 2 all in one line such as Medicare, and some (such as BCBS) require the code in separate line with description of each bacterium detected.
 
aamipatel said:
I do replied to your message earlier on the main post and then realized you will not get the notification, so replying to your post again:
"Hi Tara, based on report you posted, I would Code as follows:
87631 X 1 for Virus panel (Up to 5 target)
87486 X 1 for Chlamydia pneumoniae
87581 X 1 for Mycoplasma Pneumoniae
87798 X 1 for Bordetella pertussis
87798 X 1 XU for Bordetella Para pertussis
87541 X1 for Legionella Pneumoniae.
Some payers would pay 87798 X 2 all in one line such as Medicare, and some (such as BCBS) require the code in separate line with description of each bacterium detected.
Click to expand...
Hello, Thank you so much for your reply. We did originally bill the exact way you stated and we were getting medical records denials which we would send in and then they would hit us with we have to use an unlisted. As you can see we did and still receiving denial. Its like no matter what way they are denying just to deny. It is exhausting. My boss is frustrated and wants me to have a straight answer and I wish I could give to them.
 
Tara0513 said:
Hello, Thank you so much for your reply. We did originally bill the exact way you stated and we were getting medical records denials which we would send in and then they would hit us with we have to use an unlisted. As you can see we did and still receiving denial. Its like no matter what way they are denying just to deny. It is exhausting. My boss is frustrated and wants me to have a straight answer and I wish I could give to them.
Click to expand...
That is strange, you should have no trouble with these CPT codes for provided Dx codes, may I ask what POS you are billing with? POS should be 81 for lab. and also, are you having trouble with all codes or only 87798? My lab is just like yours in NJ and we have no trouble with these codes for reimbursement. We never billed for 87999 because we have appropriate codes for the given test by AAPC.
 
Tara0513 said:
omg I am so happy to have found this. I work in a lab in NJ but receive specimens from all over the country. We are having massive issues with this exact respiratory test along with diarrhea pathogen panel testing (3-5, 6-11 and 12-25 targets) reflex with genotypic resistance. We are receiving denials mainly united and humana stating a more specific CPT code should be used. I researched and per Medicare (as well as the DEX registry) we should be using 87999 but still being denied. We are all pulling our hair out of our head because we are following all coding guidelines and policies. We not know what else to do. It is not a diagnosis code issue. We submitted medical records as well as reconsideration/appeal and this is the response:

View attachment 7952
This is what our requisition/lab order looks like that we submitted as medical records (I blacked out the name of my laboratory):
View attachment 7953View attachment 7956
Click to expand...
Are you billing with Z code and Ta code when submitting 87999? If so you need to include detail description of the test methodology used, purpose and findings.
According to my understanding you can keep billing panel with specific CPT codes (as they do exist) but you must prove you are not billing for same intended use all CPT codes (pathogens) in the panel what can be differentiated by diagnosis codes- use medicare policy for dx (see link bellow). Use following dx listed in CMS policy if you have them on file from dr. If not you need to use 87999 because then you are billing for same intended use all tests listed.

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58710 - policy as of 07/01/25 Medicare and Medicare Advantage plans


- helpful answers

https://www.lighthouselabservices.com/why-a-z-code-identifier-doesnt-equal-moldx-reimbursement/

Please let me know if anyone was able to obtain Z-code for PCR testing and what approximate reimbursement is?

If you tried diagnosis codes and medical records instead following Cms policy please let me know as well if this has worked for you and if you bill 87798 as one line or separately (or for what payers). I just started to review this today so if I am wrong let me know please. Also I am not so sure you need modifier 59 or XU if you bill more than 1 unit for this CPT code as up to 13 units are allowed. I would say no.
 
Last edited:
aamipatel said:
That is strange, you should have no trouble with these CPT codes for provided Dx codes, may I ask what POS you are billing with? POS should be 81 for lab. and also, are you having trouble with all codes or only 87798? My lab is just like yours in NJ and we have no trouble with these codes for reimbursement. We never billed for 87999 because we have appropriate codes for the given test by AAPC.
Click to expand...
Hello,

is it possible that you get paid and they do not due to diagnosis codes? do you follow diagnosis codes listed in this policy for each CPT code in the panel with several different diagnosis or perhaps you render tests differently than them?

 
Tara0513 said:
omg I am so happy to have found this. I work in a lab in NJ but receive specimens from all over the country. We are having massive issues with this exact respiratory test along with diarrhea pathogen panel testing (3-5, 6-11 and 12-25 targets) reflex with genotypic resistance. We are receiving denials mainly united and humana stating a more specific CPT code should be used. I researched and per Medicare (as well as the DEX registry) we should be using 87999 but still being denied. We are all pulling our hair out of our head because we are following all coding guidelines and policies. We not know what else to do. It is not a diagnosis code issue. We submitted medical records as well as reconsideration/appeal and this is the response:

View attachment 7952
This is what our requisition/lab order looks like that we submitted as medical records (I blacked out the name of my laboratory):
View attachment 7953View attachment 7956
Click to expand...
If you are billing with separate CPT codes DX J06.9 and R50.9 falls into same Group one diagnosis and only 87631 will be covered.
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58761

The Group 8 CPT® codes are NOT covered for a given beneficiary on the same DOS when >1 is billed in combination with another CPT or PLA code from Groups 1 – 7 for the same intended use.

Additionally, the Group 8 CPT codes are NOT covered for a given beneficiary on the same DOS when >2 are billed for the same intended use.

NOTE: The same intended use refers to use of the same (or highly similar) ICD-10 codes on a given DOS.

Billing with 87999 requires you to submit tests methodology used/ lab results/lab order from and above listed test descriptions with explanation what are you testing for.
I would not bill 87999 as correct CPT codes do exist. I would bill separate codes follow dx and include MR. Policy may depend on Medicare Advantage versus Commercial plan.
 
aamipatel said:
That is strange, you should have no trouble with these CPT codes for provided Dx codes, may I ask what POS you are billing with? POS should be 81 for lab. and also, are you having trouble with all codes or only 87798? My lab is just like yours in NJ and we have no trouble with these codes for reimbursement. We never billed for 87999 because we have appropriate codes for the given test by AAPC.
Click to expand...
Hello, do you bill like this to UHC and other policies as well with only difference of 87798 as one or two lines? Thank you. Daniela P.
 
Hi! So yes, we have registered with the DEX and obtained the DEX Z code, and per their feedback from the registry they recommended 87999. We even received an appeal response (with medical records attached) from United Healthcare stating to use 87999. Since the last response from me (I am sorry I am not receiving any notifications when people are responding to my question) we have added on top of the Dex Z code description in box 19 of what is being performed, and they seem to be processing, but again some still do deny.

Also, when billing a panel code (87631, 87506, etc) you should not really be billing that with 87798 as they conflict with each and I believe that was stated in the response above.

I appreciate all the feedback! I wish insurances were just straight to the point with this is how to bill and this is not how to bill and they were all on the same page, but how would the shareholders buy their yachts, and 3rd home in the French Riveria.
 
Tara0513 said:
Hi! So yes, we have registered with the DEX and obtained the DEX Z code, and per their feedback from the registry they recommended 87999. We even received an appeal response (with medical records attached) from United Healthcare stating to use 87999. Since the last response from me (I am sorry I am not receiving any notifications when people are responding to my question) we have added on top of the Dex Z code description in box 19 of what is being performed, and they seem to be processing, but again some still do deny.

Also, when billing a panel code (87631, 87506, etc) you should not really be billing that with 87798 as they conflict with each and I believe that was stated in the response above.

I appreciate all the feedback! I wish insurances were just straight to the point with this is how to bill and this is not how to bill and they were all on the same page, but how would the shareholders buy their yachts, and 3rd home in the French Riveria.th
Click to expand...

This is from UHC portal you only use Z code in the following scenarios for molecular testing it says 65+ age Medicare patients see whole presentation following the link below maybe; try to bill 87999 without Z code include requisition lab order and panel description maybe only?"​


" Molecular Test Z-Code Program (DEX)​

Services Requiring Z-Codes​

Services requiring Z-Codes:
 
Last edited:
Tara0513 said:
Hi! So yes, we have registered with the DEX and obtained the DEX Z code, and per their feedback from the registry they recommended 87999. We even received an appeal response (with medical records attached) from United Healthcare stating to use 87999. Since the last response from me (I am sorry I am not receiving any notifications when people are responding to my question) we have added on top of the Dex Z code description in box 19 of what is being performed, and they seem to be processing, but again some still do deny.

Also, when billing a panel code (87631, 87506, etc) you should not really be billing that with 87798 as they conflict with each and I believe that was stated in the response above.

I appreciate all the feedback! I wish insurances were just straight to the point with this is how to bill and this is not how to bill, and they were all on the same page, but how would the shareholders buy their yachts, and 3rd home in the French Riveria.
Click to expand...
Lab Corp bills 0202U see the link https://www.labcorp.com/tests/139845/respiratory-pathogen-panel
But that is according to our coder CPT only for certain manufacturers.
Summary
This is a Proprietary Laboratory Analyses (PLA) code, meaning that the code applies to only one unique lab test made by a specific manufacturer or performed by a specific lab. Report 0202U for the BioFire® FilmArray® Respiratory Panel 2.1 (RP2.1) from BioFire® Diagnostics, which is an automated PCR test on a nasopharyngeal specimen for the most common viral and bacterial respiratory pathogens, including SARS–CoV–2.

Maybe they refer to CPT 0202U when they want you to bill with one panel code try to appeal explaining what lab kit or machinery you are using when billing with separate CPT codes.
 
You must log in or register to reply here.
Top