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Patricia Posted Wed 07th of February, 2018 16:02:03 PM
WE ARE GETTING DENIALS ON THE CPT STATING EXPERIMENTAL? IS THIS CORRECT? ALSO THE OFFICE WANTS TO CHANGE TO CPT 87634... I AM NOT SURE ABOUT THE 87634 AND FEEL THE 87801 IS DENYING IN ERROR... PLEASE ADVISE. THANKS,
SuperCoder Answered Thu 08th of February, 2018 06:09:12 AM

Hi Patricia,

According to Medicare guidelines, the experimental codes are not reimbursed. In addition, Medicare does not cover items and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and determined to be any of the following:

  • Not generally accepted in the medical community as safe and effective in the setting and for the condition for which it is used.

  • Not proven to be safe and effective based on peer review or scientific literature.

  • Not medically necessary in the particular case.
  • Furnished at a level, duration or frequency that is not medically appropriate.

  • Not furnished in accordance with accepted standards of medical practice.

  • Not furnished in a setting (such as inpatient care at a hospital or SNF, outpatient care through a hospital or physician’s office, or home care) appropriate to the patient’s medical needs and condition.

    Additionally, only one unit of 87798 or 87801 for single or multiple-organism tests, respectively, to ensure that infectious disease testing services are paid appropriately. CPT codes 87631-87633 were introduced in 2013 for procedures that detect multiple respiratory viruses in a single multiplex reaction. 

Patricia Posted Thu 08th of February, 2018 13:27:59 PM
Thanks for your response, I assume the 87634 is included in this. correct?
SuperCoder Answered Fri 09th of February, 2018 01:54:00 AM

Hi Patricia,

According to Medicare guidelines, the rationale behind the use of CPT code 87634 for office use is that this code has similar methodology as 87801.

Please find the atached link for clarity :

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2018–CLFS-Test-Codes.pdf

 

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