How To Use CPT Code 87210

CPT 87210 is a code used for wet mount smear examination of a primary source with interpretation for infectious agents. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 87210.

1. What is CPT 87210?

CPT 87210 is a code used in the medical field for the wet mount smear examination of a primary source with interpretation for infectious agents. This test is performed by a lab analyst or microbiologist to identify the presence of living parasites, clue cells, or other agents of interest in a specimen. The code is used by medical coders and billers to accurately document and bill for this specific laboratory service.

2. 87210 CPT code description

The official description of CPT code 87210 is: “Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)”.

3. Procedure

The 87210 CPT code procedure involves the following steps:

1. Collection of the specimen from the patient, usually on a swab or placed directly on a microscope slide.
2. Preparation of the wet mount by adding saline, KOH, or India ink, depending on the specimen type and the agent to be examined.
3. Examination of the wet mount under a microscope to identify the presence of living parasites, clue cells, or other agents of interest.
4. Interpretation of the findings by the lab analyst or microbiologist.
5. Documentation of the results and communication to the ordering clinician.

4. Qualifying circumstances

Patients eligible to receive CPT code 87210 services are those who require a wet mount smear examination for the detection of infectious agents. This may include patients presenting with symptoms suggestive of an infection, such as vaginal discharge, skin lesions, or respiratory symptoms. The test may also be ordered as part of a routine screening or diagnostic workup for certain conditions.

5. When to use CPT code 87210

It is appropriate to bill the 87210 CPT code when a wet mount smear examination of a primary source with interpretation for infectious agents is performed. This may be in cases where the clinician suspects an infection or as part of a routine screening or diagnostic workup. The code should be used to accurately document and bill for this specific laboratory service.

6. Documentation requirements

To support a claim for CPT 87210, the following information needs to be documented:

• Patient’s demographic information, including name, date of birth, and insurance information.
• Ordering clinician’s information, including name, contact details, and National Provider Identifier (NPI) number.
• Date and time of the specimen collection.
• Type of specimen collected and method of collection (e.g., swab, direct smear).
• Details of the wet mount preparation, including the type of solution used (e.g., saline, KOH, India ink).
• Results of the wet mount examination, including the presence or absence of infectious agents and any other relevant findings.
• Interpretation of the results by the lab analyst or microbiologist.
• Communication of the results to the ordering clinician.

7. Billing guidelines

When billing for CPT code 87210, it is important to follow the appropriate guidelines and rules. These may include:

• Ensuring that the service is medically necessary and supported by the patient’s clinical presentation and history.
• Accurately documenting the procedure, including the specimen collection, wet mount preparation, examination, and interpretation.
• Using the correct CPT code (87210) to represent the specific service provided.
• Submitting the claim with the appropriate diagnosis codes to support the medical necessity of the service.
• Following any payer-specific guidelines or requirements for billing and documentation.

8. Historical information

CPT 87210 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2001, with the previous descriptor being “Smear, primary source, with interpretation; wet mount with simple stain, for bacteria, fungi, ova, and/or parasites”.

9. Similar codes to CPT 87210

Five similar codes to CPT 87210 and how they differentiate are:

1. CPT 87220: This code is used for tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites, such as scabies.
2. CPT 87205: This code is used for smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types.
3. CPT 87206: This code is used for smear, primary source with interpretation; fluorescent and/or acid-fast stain for bacteria, fungi, or parasites.
4. CPT 87209: This code is used for smear, primary source with interpretation; complex special stain (e.g., trichrome, iron) for ova and parasites.
5. CPT 87230: This code is used for toxin or antitoxin assay, tissue culture or other methods, for the detection of Clostridium difficile.

10. Examples

Here are 10 detailed examples of CPT code 87210 procedures:

1. A patient presents with vaginal discharge, and the clinician orders a wet mount smear examination to check for the presence of Trichomonas vaginalis.
2. A patient with a persistent cough and respiratory symptoms undergoes a wet mount smear examination of sputum to identify potential infectious agents.
3. A patient with a skin lesion has a wet mount smear examination performed to detect the presence of parasites, such as scabies mites.
4. A patient with a history of recurrent urinary tract infections has a wet mount smear examination of urine to identify the presence of bacteria or yeast.
5. A patient with suspected meningitis undergoes a wet mount smear examination of cerebrospinal fluid to detect the presence of Cryptococcus neoformans.
6. A patient with a persistent sore throat has a wet mount smear examination of a throat swab to identify potential bacterial or fungal pathogens.
7. A patient with a history of gastrointestinal symptoms undergoes a wet mount smear examination of stool to detect the presence of parasites, such as Giardia lamblia.
8. A patient with a suspected eye infection has a wet mount smear examination of conjunctival secretions to identify the presence of bacteria or other infectious agents.
9. A patient with a suspected wound infection has a wet mount smear examination of wound exudate to identify the presence of bacteria or other pathogens.
10. A patient undergoing a routine gynecological examination has a wet mount smear examination of vaginal secretions to screen for the presence of potential pathogens.