Unanswered Panel Code

[MICHELLEK_76201]

Hello,

I would like to know if there is a code payable for the following tests. According to CMS Article A58575 87633. UHC is not paying for more than 6 panels for Respiratory. Article A58720 Group 8, you can not test more the 2x for the same intent. I would like to know if there is another code(s) or a panel code that can be used. Perhaps 87631 for the 3-5 panel but i wouldn't know how i can bill 2nd panel for another 4 panel.

87635 - PCR testing for microbial identification - amplified probe.
severe acute respiratory syndrome coronavirus 2 (SARS-CoV) (Coronavirus disease [COVID-19]), amplified probe technique
87631 - PCR testing for Coronavirus COVID-19 up to 5 respiratory pathogens
Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets

Influenza AH1
Influenza AH1-B
Influenza AH3
Influenza B
Rhinovirus/Enterovirus
Adenovirus
Human Metapneumovirus (HMPV)
Human Parainfluenza virus1
Human Parainfluenza virus2
Human Parainfluenza virus3
Human Parainfluenza virus4
Coronavirus 229E
Coronavirus NL63
Coronavirus OC43
Coronavirus HKU1
Respiratory Syncytial virus A
Respiratory Syncytial virus B

87581 – Mycoplasma pneumoniae - PCR testing for microbial identification - amplified probe
87486 – Chlamydophila pneumoniae - PCR testing for microbial identification - amplified probe
87798 – 2 units: Bordetella pertussis - PCR testing for microbial identification - amplified probe
Bordetella Parapertussis - PCR testing for microbial identification - amplified probe
Thanks,
Michelle

 

[JenniferD_91853]

Hello Michelle,


Thank you for your detailed inquiry regarding billing codes for respiratory pathogen panels. Based on the information provided and current CMS guidelines, here's an analysis of the billing options and limitations:

CMS Coverage Guidelines​

1. CPT Code 87633: This code, representing a respiratory pathogen panel with 12–25 targets, is not covered by Medicare as per Article A58575. PDL Labs+4Novitas Solutions+4Quest Diagnostics+4
2. CPT Code 87631: This code covers panels with 3–5 respiratory pathogens and is generally covered when medically necessary.
3. CPT Codes 87581, 87486, 87798: These codes represent individual pathogen tests (e.g., Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella pertussis, Bordetella parapertussis). They are typically covered when billed individually and supported by appropriate medical necessity documentation.

Billing Multiple Panels​

According to CMS Article A58720, when billing multiple tests for the same intended use (e.g., respiratory pathogen detection), the following limitations apply:

• Group 8 Codes: Only two tests for the same intended use are covered per date of service. Billing more than two tests for the same intended use on the same date is not covered. Palmetto GBA
• Same Intended Use: Refers to tests ordered for the same clinical purpose, even if they target different pathogens.

Recommendations​

• Use of CPT 87631: For panels testing 3–5 pathogens, CPT 87631 is appropriate. Ensure that each panel targets different pathogens to justify multiple panels.
• Individual Pathogen Testing: For additional pathogens beyond the initial panel, consider billing individual tests using CPT codes like 87581, 87486, and 87798, provided each is medically necessary and properly documented.
• Medical Necessity Documentation: Ensure that each test or panel is supported by clinical documentation justifying its necessity.
• Avoid Non-Covered Codes: Be cautious with codes like 87633, which are explicitly non-covered by CMS.Codemap+2Quest Diagnostics+2AAPC+2

Conclusion​

While CPT 87631 can be used for panels of 3–5 pathogens, billing multiple panels or additional tests requires careful consideration of CMS guidelines to ensure coverage. Always support each test with appropriate medical necessity documentation and be aware of the limitations on the number of tests per date of service.


If you need further assistance or have specific scenarios you'd like to discuss, feel free to provide more details.

 

[MICHELLEK_76201]

Thank you for your response.


UHC recommended reporting CPT 87798 x6 to reflect multiple respiratory organisms tested. However, I’m unsure how this would be correct when specific CPT codes exist for several of those organisms (e.g., 87635 for SARS-CoV-2, 87581 for Mycoplasma pneumoniae, and 87486 for Chlamydophila pneumoniae).


Additionally, based on CMS Article A58720, CPT 87631 (Group 1) cannot be billed with 87581, 87486, or 87798 (Group 8) on the same date of service due to coverage grouping conflicts.


Would there be any compliant way to report a comprehensive panel (e.g., 6 organisms)?


I appreciate your guidance on this.


Thanks,
Michelle