Hi,
To give you the best most accurate response I would need to know a little more information about the UTI test. Is the testing being done inpatient or outpatient? Is the test a multiplex PCR panel test (are multiple pathogens being tested aka Panel test), If the testing is done in the outpatient setting and if it is a multiplex PCR panel test, generally most of the larger infectious agent PCR panel tests are considered investigational/experimental and/or they are considered not medically necessary (respiratory, UTI, Wound, Nail, STI, GI, ear, eye, soft tissue, etc.,). (Generally speaking, larger panels are those with 5 or more pathogens)
I feel like the following Medicare rule is being applied to the I/E denials you are seeing on your Medicare claims:
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.
You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
Also, if the testing is being performed on a Medicare patient be sure to check out any related LCD's and the related articles especially those in MolDx states. MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing. Also check out the Response to Comments: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing document. The Non-MolDX states also have LCD's and articles also related to PCR panel tests (GI and Resp., ETC.,).
CMS National Coverage Policy
- Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary
- 42 CFR §410.32(a) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
- CMS Internet-Only Manual, Pub. 100-02, Medicare Policy Manual, Chapter 15, §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, §80.1.1 Certification Changes
I use the LCD's and articles daily. Another resource I use almost daily is the DEX Diagnostics Exchange -
https://www.dexzcodes.com/
For Commercial - Most payers have specific guidelines around infectious agent testing. Look at the payer's policies.
Additional information not related to your question but thought I would share because it is very important when coding multiplex infectious agent 'panel' tests:
Unbundling is another
big issue I see day-in and day-out with these types of "panel" tests. Please read the appropriate related LCDs and article, they provide a wealth of information on billing and coding infectious agent panel tests.
Also, Novatis has a great article available on this topic titled, '
Bill Infectious Disease Panels Correctly' and the LCD/Articles clearly define what a "panel" is as well as offer assistance on how those panels should be billed.
I hope you find the information helpful. I know this is way more information than what you were looking for and I hope I did not cause you more confusion.
Feel free to reach out if you have any additional questions.