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

 

[MICHELLEK_76201]

Per UHC, CPT 87798 may be billed for individual organisms instead of using CPT 87631. Would it be appropriate to report CPT 87798 for up to three of the individual organisms listed under CPT 87631, given that 87631 cannot be billed in conjunction with 87581, 87486, or 87798?


Organisms:

• Influenza A H1
• Influenza A H1-B
• Influenza A H3
• Influenza B
• Rhinovirus/Enterovirus
• Adenovirus
• Human Metapneumovirus (HMPV)
• Human Parainfluenza Virus 1
• Human Parainfluenza Virus 2
• Human Parainfluenza Virus 3
• Human Parainfluenza Virus 4
• Coronavirus 229E
• Coronavirus NL63
• Coronavirus OC43
• Coronavirus HKU1
• Respiratory Syncytial Virus A
• Respiratory Syncytial Virus B

I appreciate your assistance.

Thanks,
Michelle

 

[JenniferD_91853]

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

Thank you for you question. Please let me know if this information is of assistance.​

Understanding CPT Codes for Respiratory panels:

• 87798 – Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified (NOS); amplified probe technique, each organism
  → This is a generic “catch-all” code for molecular testing when no specific code exists for the organism being tested.
• Specific codes (like 87635, 87581, 87486) should always be reported instead of 87798 when applicable. CPT instructs that 87798 should not be used for organisms that have a specific CPT code.

When UHC recommends 87798 x6, here's the nuance:​

They may be assuming all 6 organisms tested do not have unique CPT codes, or they are directing you to avoid bundling conflicts with other codes like 87631, which represents a multiplex panel.

However, per CPT guidelines and CMS Article A58720:​

• CPT 87631 (Respiratory panel by multiplex PCR for 3–5 targets) includes testing for:
  
  • Influenza A & B
  • RSV
  • SARS-CoV-2 (if applicable, varies by payer)
  • Parainfluenza, etc.
• CMS Coverage Conflicts (Article A58720):
  
  • You cannot bill 87631 + individual codes (87486, 87581, 87798) on the same date of service because they are in mutually exclusive Groupings (1 vs. 8).

Compliant Coding Strategy for 6-Organism Panel:

You have three options, depending on test composition and payer rules:

Option 1: If ≥5 organisms are covered in 87631​

Bill CPT 87631 alone
Do not bill individual organism codes like 87581, 87486, or 87798 on the same DOS

Option 2: If panel includes organisms not covered in 87631​

• Use specific CPT codes (e.g., 87635, 87581, 87486) for identifiable organisms
• Use 87798 only for those that lack a designated CPT code

But do not combine 87631 with any from Group 8 (A58720) like 87581, 87486, 87798 on the same DOS

Option 3: If payer (like UHC) instructs use of 87798 x6​

Only follow this if:

• You're testing 6 organisms that lack designated CPTs
• OR if their policy explicitly restricts use of the specific codes for panels (less common but not unheard of)

Document payer instructions in the chart to defend against audits



Best Practice

• Use specific codes first, only use 87798 when no specific code exists
• Never mix multiplex panel codes like 87631 with component codes (like 87581, 87798) unless explicitly allowed
• Reference payer-specific LCDs/NCDs and policies (e.g., UHC’s reimbursement guidelines)

 

[JenniferD_91853]

Per UHC, CPT 87798 may be billed for individual organisms instead of using CPT 87631. Would it be appropriate to report CPT 87798 for up to three of the individual organisms listed under CPT 87631, given that 87631 cannot be billed in conjunction with 87581, 87486, or 87798?


Organisms:

• Influenza A H1
• Influenza A H1-B
• Influenza A H3
• Influenza B
• Rhinovirus/Enterovirus
• Adenovirus
• Human Metapneumovirus (HMPV)
• Human Parainfluenza Virus 1
• Human Parainfluenza Virus 2
• Human Parainfluenza Virus 3
• Human Parainfluenza Virus 4
• Coronavirus 229E
• Coronavirus NL63
• Coronavirus OC43
• Coronavirus HKU1
• Respiratory Syncytial Virus A
• Respiratory Syncytial Virus B

I appreciate your assistance.

Thanks,
Michelle

Yes, under UHC-specific guidance, it can be appropriate to report CPT 87798 for individual respiratory organisms that are typically grouped under CPT 87631, as long as:

1. You do not bill 87631 on the same date of service, and
2. You use 87798 only for organisms without their own specific CPT codes.

Why this can be appropriate for UHC:​

UHC has payer-specific policies that allow or prefer billing individual organisms with 87798 rather than using the comprehensive multiplex panel code 87631—likely to control costs or limit bundling.

Since CMS Article A58720 prohibits billing 87631 together with 87581, 87486, or 87798, choosing to skip 87631 and instead report multiple 87798 units can be a compliant alternative—if no specific CPT code exists for the tested organisms.

 

[MICHELLEK_76201]

Thank you so much this is very helpful! but last question I would like to know if Article A58761 is another way to submit the code set 87631,87581,87486,87798?

"The test panel is a single test with multiple components and is characterized by a single unit of service (UOS=1). A panel cannot be unbundled and billed as individual components regardless of the fact that the testreports multiple individual pathogens and/or targets. If additional organisms are not included in a panel,testing for those organisms separately may be reasonable and necessary when ordered in addition to the panel and supported by documentation in the medical record."

thanks,
Michelle