Last Modified: 9/5/2023
Location: FL, PR, USVI
Business: Part B
First Coast regularly performs data analysis to identify services that are frequently not billed and coded correctly per Medicare guidelines. Recently, we found three common errors for providers billing infectious disease panels to Medicare. Read on to learn how to bill these services correctly.
Error 1: Billing multiple codes for a single test
We found that providers are incorrectly billing multiple codes to describe a single-test kit that evaluated multiple infectious agents.
First Coast has two LCDs that address billing for multiple organism test panels. Here are a few important reminders about the coverage and billing policies:
• Codes covered: 87428, 87631, 87636, 87637, 87913, 0240U, and 0241U
• Codes not covered: 87632, 87633, 0115U, 0202U, 0223U, 0225U, and 0373U
• Per the LCD, respiratory panels that evaluate more than five respiratory pathogens are not medically reasonable and necessary in the Medicare Part B outpatient setting. It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.
• Per this LCD, Medicare will allow only one GIP multiplex panel (CPT code 87505, 87506 or 87507) per day per beneficiary by the same or different provider.
• When billing CPT code 87507 and reporting ICD-10-CM code R19.7, one of the immunosuppression diagnosis codes listed in Table 3 must also be reported.
Please note: L38227 was updated on October 16, 2022, with a change in the dual diagnosis requirement for CPT code 87507. For dates of service 12/30/2019 - 10/15/2022: When reporting ICD-10-CM code K56.0, either ICD-10 Code R10.84 or R11.2 must also be reported.
Also note, CPT codes describing a test for multiple infectious agents are billed with only one unit of service if one procedure, one methodology, and/or one test kit is used to perform the test. Examples of these codes include:
• 87800 – Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
• 87801 – Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
When multiple procedures, multiple methodologies, or multiple kits are used to evaluate multiple infectious agents, the units of service reported must equal the number of different procedures, methodologies, or kits used to perform the test.
Error 2: Insufficient documentation
When billing with culture CPT codes (e.g., 87150), we noted that some providers submitted documentation without clear evidence demonstrating that a patient’s specimen had been cultured.
When billing culture CPT codes, your documentation must indicate the type of culture that was performed or a description of the culture methodology in order to support the selected CPT code.
Error 3: Modifiers billed to inappropriately bypass editing
Finally, we identified providers using modifiers that were unnecessary for the CPT codes billed and appeared to be appended for the purpose of bypassing coding edits.
• Section E: Modifiers and modifier indicators
• Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier shall not be appended to a HCPCS/CPT code solely to bypass a NCCI procedure-to-procedure edit if the clinical circumstances do not justify its use.
The NCCI Policy Manual, Chapter 10
, provides guidance for properly billing infectious disease panels to Medicare: (Not all items in the NCCI Policy Manual, Chapter 10, Section K. are indicated below.)
• Section K: Microbiology
• 1. CPT codes 87040-87158 describe microbiological culture studies. The type of culture is coded to the highest level of specificity regarding source, type, etc. When a culture is processed by a commercial kit, report the code that describes the test to its highest level of specificity. A screening culture and culture for definitive identification are not performed on the same day on the same specimen and therefore are not reported together.
• 2. Infectious agent molecular diagnostic testing using nucleic acid probes is reported with CPT codes such as 87471-87801, 87910, 87901, 87906, 87912, 87902, 87903, and 87904. These CPT codes include all the molecular diagnostic analyses/processes.
• 5. With one exception, CMS policy prohibits separate payment for testing for a single microorganism from an anatomic site by more than one methodology. For example, if a physician performs tests for cytomegalovirus antigen at an anatomic site by immunoassay (CPT code 87332) and by nucleic acid direct probe (CPT code 87495), only one of these codes may be reported for the testing.
• If a culture independent diagnostic testing method is positive for a microorganism, it may be medically reasonable and necessary to additionally culture the microorganism for drug sensitivity testing or (rarely) for community surveillance identification.
• 6. CPT codes 87483 (Multiplex infectious agent detection by nucleic acid methodology for central nervous system pathogens), 87505-87507 (Multiplex infectious agent detection by nucleic acid methodology for gastrointestinal pathogens), and 87631-87633 (Multiplex infectious agent detection by nucleic acid methodology for respiratory virus) describe multiplex testing procedures for multiple microorganisms using reverse transcription and/or amplified probe techniques. The codes describe an anatomic region and the number of “targets” tested.
• If one of these multiplex tests is performed and additional testing by these methodologies for additional microorganisms that might cause disease in the anatomic region described by the code descriptor is performed, only one multiplex testing code summing the testing for all “targets” shall be reported. The code descriptors identify some microorganisms, but not all, that might be tested by these methodologies for the respective anatomic regions.
• If it is medically reasonable and necessary to test by a different methodology or for other types of microorganisms not included in the multiplex test that might cause disease in the respective anatomic region, the test may be reported separately.
• The same organism could be a target in one panel reflecting one organ system and a target in a different organ system when testing a different specimen. The same organism could be the target tested on each of two or more specimens from different anatomic sites.
• Section M: Medically unlikely edits
• 15. In the case of tests for infectious agents, methodologies include detection by immunofluorescence, immunoassay, or nucleic acid probe techniques. A single laboratory procedure shall be reported as one unit of service whether it generates one or multiple results. CPT codes that test for a single infectious agent that employ one procedure, one methodology, or one test kit are reported with one unit of service.
• CPT codes that test for multiple infectious agents are reported with one unit of service if one procedure, one methodology, or one test kit is used to perform the test (e.g., 87300, 87451, 87800, 87801). When multiple procedures, multiple methodologies, or multiple kits are medically necessary and used to perform a test for multiple infectious agents, the units of service reported for CPT codes that identify multiple infectious agents equals the number of different procedures, methodologies, or kits used to perform the test.
• For example, if a provider tests for 5 different species of an infectious agent using a single multiple-result test kit, only one unit of service for that test kit may be reported. However, if a provider tests for three different species of an infectious agent by using three different single result test kits, the provider may report three units of service of the appropriate CPT code.
• Section N: General policy statements
• 8. Medicare does not pay for duplicate testing. Multiple tests to identify the same analyte, marker, or infectious agent shall not be reported separately. For example, it would not be appropriate to report both direct probe and amplified probe technique tests for the same infectious agent.
Please be sure to review the medical policies to ensure you properly document the medical reasonableness and necessity of the services billed. In addition, use provided policies and guidelines to select coding that accurately describes the services performed, including a correct count of the units of service.
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