Question: We’ve been involved in testing for enteric adenoviruses types 40 and 41 from fecal specimens. We perform two separate fluorescent antibody tests, one for each strain. We used to get paid for both tests, but are now getting denials. What could be the problem?
Answer: Depending on the payer, the problem might be a change in medically unlikely edits (MUEs).
If the test you’re performing is 87260 (Infectious agent antigen detection by immunofluorescent technique; adenovirus), as it appears from your description, Medicare’s MUE limit for the code is one unit.
In the past, the Centers for Medicare and Medicaid Services (CMS) allowed you to override this MUE limit by submitting each test on a separate claim line and appending modifier 59 (Distinct procedural service) to the subsequent tests. The caveat was that you had to perform multiple, individual tests, not identify multiple strains with a single test. It appears that you meet that criterion.
Change: CMS has changed the MUE for codes 87260-87660 (Infectious agent antigen detection…) from a claim-line edit to a date-of-service edit. The MUE limit for the test you’re performing (87260) is one. That means you can no longer report multiple units of 87260 by submitting them on separate claim lines with modifier 59. Medicare will pay for only one unit of 87260 per date of service.