Wiki Repeat Lab test, different DOS

[agibbons]

I am trying to find guidelines regarding billing for repeat testing on separate dates of service. A provider performed a Covid Lab test 87426 prior to elective major surgery, but the surgery was rescheduled after the test was performed so the patient had to be re-tested for the same Covid lab test 87426 to be within 48 hours of the surgery. The provider wants to bill for both tests. What resource can I provide to support billing or not billing for the repeat test?

Personally I find it difficult to support the medical necessity of both tests, especially if it was due to provider scheduling and not a medical condition, but unable to provide that validation anywhere. We are required to have a negative covid test within 48 hours of any major elective surgery in the State of Iowa, so that is why the provider wants to bill both.

 

[sab001]

The test WAS medically necessary at the time it was ordered. Documenation in the patient's medical record should support that. A new order will be needed for the next occurrence.

Payors are beginning to develop policies regarding 'Pre-procedureal COVID-19 diagnostic testing.' I did a quick search and found one for one of the Blue's plans. It does require a valid physician order. Either 87635 or 87426. Appropriate diagnosis codes would be Z01.81, Z01.810, Z01.811, Z01.812, Z01.818 (per the Blues policy.)

If you run up against a denial, just appeal indicating the surgery was rescheduled.

 

[thomas7331]

I agree with the post above. If the test is a necessary part of the surgery, as you've indicated, then under the circumstances I would not worry about billing the second test as that is still a requirement in order to complete the procedure. During this unique time of pandemic, I think all providers and payers are trying to do their best to get us through this, and I can't see anyone quibbling over the fact that a test here or there has to be paid for twice in order to ensure safety for everyone.

More generally speaking, from a CMS perspective, the definition of medical necessity includes those items "reasonable and necessary for the diagnosis or treatment of an illness or injury" and not "furnished primarily for the convenience of the patient, the attending physician, or other physician or supplier." So if the rescheduling of the procedure was solely done for the convenience of the provider, then perhaps it could be considered not medically necessary and a payer could potentially argue that it the responsibility of the provider who rescheduled the procedure to bear that cost. But providers do genuinely need to reschedule procedures at times - it's a normal part of managing their practices. That does not make the test medically unnecessary.

In your place, as long as this isn't something that is happening so frequently that it might be considered an abuse of the system, I would just let it go. As the last posts states, if a payer has a problem with an excessive frequency of a particular test, they will set a policy limit for how often they will cover it. It's good for coders, as the eyes and ears of a practice, to keep an eye out for potentially non-compliance activities, but it's not really a coder's scope or responsibility to be the judge of whether or not something is or isn't medically necessary in every given instance - that's best left to the providers. If a service is rendered in good faith, then it should be coded and billed as such.