[Ohioaap-practicemanagers] CareSource denials of rapid strep tests

[Michael Chamberlin]

Thanks for the info.  We do use the QW modifier.  We have just seen a few
denials in the past week, so I'm concerned that we may see more soon.  A
colleague (who has experience working for a managed Medicaid in another
state) suggested using the J02.8 code (acute pharyngitis due to other
specified organisms).    I think we may try that.


Michael Chamberlin, M.D., FAAP
Pediatric Assoc. of Mt Carmel
4371 Ferguson Dr
Cincinnati, OH  45230
513-752-3650
513-752-3387 (fax)



On Thu, Nov 11, 2021 at 11:46 AM Michele Dritz <michele.dritz at gmail.com>
wrote:

> Our billing person also had recently told us providers about some
> challenges she was running into around coding & reimbursement for
> pharyngitis vs strep codes.  I reached out to her about this message & here
> are some of her comments:
>
>
>    - We have not had any problems with denials of procedure code 87880. I
>    just double checked our most recent zero pay report for October and there
>    were not any on that either. For the most part we submit that procedure
>    code with diagnosis code J02.9 or J02.0 (if they test positive for strep).
>    My thought is that the practice may not using the QW modifier to indicate
>    the test is CLIA waived. If you can, pass that information on and maybe
>    that will help them.
>
> BUT ALSO:
>
>
>    - We did have issues with Anthem denying the office visit (ex: 99213)
>    when we used J06.9 (URI) with J02.0 (Streptococcal pharyngitis) because
>    J06.9 includes streptococcal upper respiratory infection. I now just drop
>    dx code J02.9 (acute pharyngitis, unspecified) if the strep test comes back
>    positive and only submit the J02.0 code. To the best of my knowledge, we
>    haven't had any problems receiving payment for 87880,QW.
>
> As a provider we’re kind of stuck because our EMR requires us to choose an
> ICD-10 code BEFORE we can even sign-off on an order for a nurse to do.  So
> I need to call the dx something initially, but then can’t remove that dx
> code retroactively after the POC strep shows positive because it’s already
> embedded in my note as the dx code associated with my original test order.
>
> It’s annoying to have to do any work around because of these seemingly
> nit-picky things, but that’s been her solution that helped address the
> issue.
>
> Good luck!
>
>
> Michele
>
> --
> Michele Dritz
>
>
> On November 10, 2021 at 2:27:41 PM, Michael Chamberlin via
> Ohioaap-practicemanagers (ohioaap-practicemanagers at lists.deltaforce.net)
> wrote:
>
> We are getting denials for rapid antigen strep testing (87880) when using
> "acute pharyngitis, unspecified J02.9."  The guidelines say that if viral
> pharyngitis is suspected then a rapid strep test should not be done so I
> would understand a denial of the claim if "viral pharyngitis" is used.  We
> may try using the ICD 10 code for "pain in throat" but it is silly that we
> have to guess at what is the appropriate code to use for this.
>
> Has anyone else experienced this before?  What ICD 10 code do you link
> with a rapid strep test?
>
> Mike
>
> Michael Chamberlin, M.D., FAAP
> Pediatric Assoc. of Mt Carmel
> 4371 Ferguson Dr
> Cincinnati, OH  45230
> 513-752-3650
> 513-752-3387 (fax)
>
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