Wiki Stool Testing Coding

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Tara0513

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Hello!

United Healthcare has been denying a lot of our claims stating that a number of codes that we have billed are "Not supported. There is a more appropriate laboratory panel CPT code that should be billed when one or more CPT codes are included in the same panel. Here are the tests we are billing and the CPT codes; can some please tell me if this is wrong. I do not see a panel code for the testing we are performing:

Assay of Calprotectin Fecal-83993
Elastase Pancreatic Fecal-82656
Fat/Lipids Feces-82705
Ova & Parasites direct smears 87177 & 87209
Fecal Immunochemical Test (FIT- 82274
Lactoferrin Fecal- 83631
H-pylori Stool- 87338
Anti-TTG, Fecal by ELISA- 83520
Anti-Gliadin, Fecal by ELISA-83520
Bile Acids, Fecal by ELISA-83520
Listeria monocytogenes, Fecal by Real-Time PCR- 87798

We did run a GIPP-Gastrointestinal Pathogen Panel as well on this patient which we coded as 87506 because we tested:
NOROVIRUS GI/GII
ROTAVIRUS A, B, C
CAMPYLOBACTER (C. JEJUNI / C. COLI / C. UPSALIENSIS)
SALMONELLA SPP.
SHIGA-LIKE TOXIN-PRODUCING E. COLI (STEC)
SHIGELLA/ENTEROINVASIVE E. COLI (EIEC)
TOXIGENIC CLOSTRIDIOIDES DIFFICILE
VIBRIO SPP. (V. PARAHAEMOLYTICUS / V. VULNIFICUS / V.
CHOLERAE)
YERSINIA ENTEROCOLITICA
ENTAMOEBA HISTOLYTICA
GIARDIA LAMBLIA

I do not believe there is a panel code for the additional stool testing that was performed besides the GIPP. United has been playing these games with a lot of our claims lately using this denial. I just wanted to post here to make sure I am not missing anything because I have researched.


I appreciate reading this long question and I look forward to receiving input on this issue.
 
Is it the ICD10 codes that are not supporting the tests ordered?
Is there a DNA or RNA test that would look at these?
 
Last edited:
Tara
Are you billing as first dx code with these labs disease ICD10 or just Z dx codes? Why is provider ordering them?
Lady T
 
We are using medically necessary dx codes ex. R19.7. We have compared all insurance medical policies to make sure we are complying with the reasoning for this testing. We are now getting hit with this new denial, and humana has now latched onto this bandwagon. I have looked and I see a PLA code 0369U - GI assay (Gastrointestinal Pathogen with ABR) from Lab Genomics LLC, Thermo Fisher Scientific. The test evaluates a fecal specimen using a multiplex amplified probe technique to detect 31 bacterial, viral, and parasitic organisms and 21 associated antibiotic–resistance genes. We do run an antibiotic resistance if there is a positive bacterium but we are not testing 31 organisms, so this does not hold true to what we are performing. I am also confused on when to use PLA. This code states a specific lab using a specific machine, now we do use Thermo Fisher but we are not Lab Genomics LLC. I am wondering if this is a lab specific code?
 
Tara0513 said:
We are using medically necessary dx codes ex. R19.7. We have compared all insurance medical policies to make sure we are complying with the reasoning for this testing. We are now getting hit with this new denial, and humana has now latched onto this bandwagon. I have looked and I see a PLA code 0369U - GI assay (Gastrointestinal Pathogen with ABR) from Lab Genomics LLC, Thermo Fisher Scientific. The test evaluates a fecal specimen using a multiplex amplified probe technique to detect 31 bacterial, viral, and parasitic organisms and 21 associated antibiotic–resistance genes. We do run an antibiotic resistance if there is a positive bacterium but we are not testing 31 organisms, so this does not hold true to what we are performing. I am also confused on when to use PLA. This code states a specific lab using a specific machine, now we do use Thermo Fisher but we are not Lab Genomics LLC. I am wondering if this is a lab specific code?
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Hi Tara
It seems payer for these lab test want dx R19.7 AND another dx of B20, or Autoimmune DsD80 block , or transplant dx code of Z94. Also this must be supported by documentation from provider. For our fecal test we use Z12.11 as last dx and the problem patient suffer with such as dx blocks of K92,K57,K63.9, K64, K59, K52, K31.9, K55, or R19.4 just to name a few.
Lady T
 
I just screen shoot United's appeal determination. They are stating for 87506, 87338 and 87798 I should use CPT code 87999. I am so confused. I NEED HELP o_O😭😭😭😭
 
CXZook said:
CPT 87506 requires a Z code per UHC policy. If you add the correct Z code to that CPT it should show to UHC that this is a separate, unique panel from the other individual test ran. The Z code is specific to the test by the performing laboratory/manufacturer. Just a thought not sure if it will help or not.

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For some reason I never saw this reply! Thank you for the response, and I apologize for the delay. So, this DOS was previous to when the Dex code was required. I was checking at least once a week for when the phase for molecular codes were required, and from what I saw the start date was the beginning of this year. please correct me if i am wrong. Now moving forward, per DEX registry they recommended 87999. So, we have been using that code and of course ding ding ding...denied! They want med recs so we submitted them as well, one claim was paid and some are still being denied. Also we have been using the DEX z code on all claims from 2025 and on but we are still receiving denials for a more appropriate code....its like insurance companies just dont want to pay!! lol
 
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