87804: Tips To Stay Away From Denials For Second-Strain Flu Testing Claims


While determining whether a patient has both A and B strains, take a look at your insurer and find out whether modifier 59 is required.

If you carry out two tests to screen for two different strains of the flu, do you report two line items on the same code? This is the issue in question as pediatric practices struggle to collect for multiple units of 87804 (Infectious agent antigen detection by immunoassay with direct optical observation; influenza).

The answer depends on your insurer’s policy for sure, however in lieu of a written directive from your payer, here are some tips that can help you get your flu test coding on the straight and narrow.

For optical analysis report 87804-QW

87804 describes the rapid flu test approved by the FDA requiring Clinical Laboratory Improvement Act (CLIA)-waived status. Use this code for detection by visual identification.

Reporting tip: Many Medicaid states need you to follow Medicare modifier guidelines and add modifier QW (CLIA-waived test) to 87804. In order to keep your coding uniform, many practices make use of modifier QW irrespective of payer.

Use 87804 coding rule while testing for strains A & B

When your office makes use of an A&B influenza test, you should code multiple units of 87804 when called for.

For an in-office test that doesn’t identify the influenza strain, report one unit of 87804. For example, if you carry out a test that picks up only the presence of influenza with a single positive/negative, you should report one unit of 87804.

If you use a product that distinguishes between influenza A &B and the doctor documents both results, you should code 87804 twice. Technically it’s two tests just done in one so you’re right in billing twice since the physician is documenting two results. If the test doesn’t differentiate, just a positive/negative then you’d bill the code once.

Take this alternative for 87804 denial

You may confront variations in the way payers need you to report multiple units of 87804. Here’s how to determine which method to use:

Best practice: Report two units of 87804 if the payer allows it. Many carriers allow you to report 87804 x 2 without a problem since the MUEs that Medicaid and some other payers use to auto-deny second and subsequent line items limits you to two units of 87804. This means that your carrier will progress two units of the code but would most likely auto-deny three or more units billed together.

For payers that don’t recognize two units of 87804 and deny the second charge as a duplicate, go for modifier 59 on the second 87804 entry. This modifier indicates that a different test was carried out to test for a distinct strain.

Fallback method: In some rare instances such as certain state Medicaid providers, you may be advised by your payer to use modifier 91 on the second listing of 87804. But then before going for this coding method, which contradicts present coding guidelines, obtain a written recommendation from the payer.

The May 2009 CPT Assistant supports the advice that modifier 59 is a better choice than modifier 91. It tells you to use modifier 59 when separate results are coded for different species or strains that are described by the same CPT code. This advice should serve to clarify the use of the modifier in these examples. As a matter of differentiation, modifier 91 is used when, in the course of treating a patient, it’s required to repeat the same laboratory test on the same day to get subsequent test results.

For more on this and for other specialty-specific articles to boost your pediatric coding, stay tuned to a good medcal coding resource like Coding Institute.


Source by Erin