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Question: What is the correct way to bill for COVID, influenza A and B, and RSV testing? We got denials for billing the tests separately, stating we should use a more appropriate code, so we tried 87637. We are also verifying that the diagnosis used is based on Centers for Medicare & Medicare Services (CMS) local coverage determination (LCD) guidelines; however, some of the Louisiana Medicaid plans are still denying due to the diagnosis. We were told to follow CMS guidelines, but I think we are. Can you help?

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Answer: According to CMS , respiratory pathogen panels that test for five or fewer pathogens in the Part B setting, such as a physician鈥檚 office or a clinical laboratory, 鈥渨ill be considered medically reasonable and necessary鈥� providing 鈥渢he outpatient setting is equipped to deliver timely results鈥� and the 鈥渢est result aids clinical management with the goal of an improved health outcome for the patient.鈥�

So, assuming your lab meets these criteria, you can use 87637 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique). As this combination code describes testing for all 4 pathogens you are trying to detect, and as an applicable combination code exists, billing with 87637 is preferable to billing separate codes for each pathogen test.

CMS lists the acceptable diagnosis codes to accompany 87637 in a separate LCD: . In total, the LCD lists 192 ICD-10-CM codes that will support medical necessity. As long as the ordering physician has reported a diagnosis that appears on this list, and you are testing in an outpatient facility, you should be able to prove medical necessity for the test and receive reimbursement for it.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC