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CPT Code 87491 | Description, Guidelines, Modifier & Example

CTP code 87491 is a medical procedure code for infectious agent identification, according to American Medical Association (AMA). This code can be used for an amplified nucleic acid probe approach.

Unless provider, state, or federal contracts and laws are specified, a laboratory panel grouping will include CPT 87491, CPT 87591, and CPT 87661. 

When a claim contains two or more single tests, the Plan will aggregate them into a single comprehensive laboratory procedure code CPT 87801.

When a provider invoices separately for two or more tests on the same day, the Plan will pay for the more comprehensive, multiple organism CPT code 87801. Reimbursement is only for one unit, regardless of the bill amount for the 87491 CTP code.

This policy covers nucleic acid (DNA or RNA) testing for the diagnosis of Sexually Transmitted Infections if CPT 87491, CPT 87591, CPT 87661, or CPT 87801 will state on professional or facility claim forms for payment (STI). A CMS-1500 or its electronic equivalent can define as professional fees for this policy. 

CPT code 87801 can detect infectious agents using nucleic acids in a more thorough and multi-organism approach. Therefore, payment will be based on a single unit of 87801, regardless of the number of units billed for a specific code.

Sexually transmitted infections (STDs), formerly known as “venereal sickness,” are becoming more common. STDs such as HPV, Chlamydia, gonorrhea, syphilis, and genital herpes are among the most common (HIV). Sexual contact, unsterile medicinal needles, nursing, delivery, and even blood transfusions can all spread STDs.

For the third year in a straight, the Centers for Disease Control and Prevention (CDC) has observed a rise in Chlamydia, gonorrhea, and syphilis cases.

These three viruses produced more than 2 million STD cases in 2016 – the most significant number ever documented. Untreated Chlamydia, the most common STD in the United States, can cause infertility, ectopic pregnancies, and pelvic inflammatory disease.

87491 CPT Code Description

CPT Code 87491 is described by the CPT manual as: “Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique.”

 STDs are becoming more common in people of all ages. Despite this, STDs continue to be devalued and can have disastrous health repercussions for people who do not have them examined and diagnosed. Therefore, the CDC recommends that each patient’s sexual history be acquired and tested and provide care for the patient and their partner.

Because the number of persons infected with STDs is increasing, clinicians may have difficulty categorizing their patients’ medical data appropriately. Therefore, to ensure proper payment, providers must accomplish the following:

  • Knowing the proper vocabulary, ICD, CPT, and modifier codes, as well as which codes best reflect the services provided, is essential.
  • Check that you are following all public and commercial insurance regulations.
  • Provide as much evidence as you can

E/M codes for history, examination, and treatment decisions are among the most prevalent. Preventative medical services may involve reporting any complaints, irregularities, or previous concerns that the patient will deal with.

With one-on-one instruction, CPT codes 99401 to 99404 are available. These codes can use to refer patients who have no symptoms of an STD to preventive STD counseling. Preventive themes discussed in person with a licensed physician should document. These categories will include Counselling in groups 99411-99412.

These codes can use for group therapy. Sexually transmitted diseases (STIs) can be passed from one person to the next by sexual contact. Women and children experience the majority of STI challenges. 

STIs can go undetected for a long time. A sexually transmitted infection (STI) while pregnant can offer substantial health hazards to the mother and her unborn child. Everyone who has a sexually transmitted disease (STI) has health risks. The STI screening tests used in the national coverage determination (NCD) are laboratory procedures.

Billing Guidelines For CTP Code 87491

CMS will cover CPT 87491 for combined Chlamydia and gonorrhea testing.

Since their initial screening, pregnant women who have engaged in high-risk sexual activity should recheck during the third trimester. If high-risk sexual behavior has occurred since the last screening, patients should check again in the third trimester and at delivery.

Expectant moms a rescreened for risk factors at the time of delivery after the initial prenatal checkup, at which the pregnancy’s diagnosis can know.

CMS will pay for gonorrhea screenings (CPT 87590, 87591, 87850, 87800). Primary care physicians must recommend, and Medicare-eligible providers must perform screening using FDA approved/cleared laboratory tests, consistent FDA-approved labeling, and in line with CLIA regulations to test for both Chlamydia and gonorrhea at the same time.

If any of the following criteria exist, the risk of the second screening remains high. Pregnant women should receive one syphilis screening for each pregnancy. If they are still at risk for STIs, they can be subject to two more screenings in the third and final trimester and during birth.

A hepatitis B screening should be performed once during each pregnancy, and if the risk of STIs persists, a second screening should perform at the time of delivery.

  • The recipient pays for two face-to-face HIBC counseling sessions of 20 to 30 minutes annually. 
  • Coinsurance and copayments can also waive.
  • The deductible is no longer required.

The STIs described in this guidance are discovered using specific laboratory testing. This policy includes information on diagnostic testing to distinguish between coverage for diagnostic and screening indications. Every year, STIs are a significant source of sickness and mortality in the United States.

 The United States Preventive Care Task Force recommends syphilis, gonorrhea, Chlamydia, and HIV testing as preventive services (USPSTF). This is because high-risk sexual behavior raises the likelihood of developing STDs.

 According to the USPSTF, women under 25 who participate in sexual activity should be on high alert for chlamydia and gonorrhea risk. Many medical organizations encourage doctors to consider adapting their routine STI examinations to the individual communities and populations they serve. 

 As a result, evidence showing the testing will likely impact the treatment of the illness the modifier 26 must include in the medical record. The laboratory or billing provider must retain a copy of the doctor’s order, which details the diagnosis or condition for which the test is ordered (s).

One service and one unit of service (UOS = 1) comprise a test panel. Even though the test indicates numerous distinct pathogens and targets, a board cannot be divided down and billed as independent components. The single test panel comprises several parts (UOS=1) run on a single platform. Testing for additional species not covered in a commission may be permitted and necessary if the patient’s medical documentation supports this further testing.

Modifiers

Modifier 59 would not apply to either of these codes because 87491 and 87591 are combined into 87150 unless there is specific documentation and a deliberate choice to use modifier 59. For further information on nucleic acid probes, consult the Pathology/Lab Services section of the NCCI Edits Manual. 

NCCI edits have a status indicator of 0, 1, or 9. Code pairs with a status indicator of 1 can pay even though they are generally not payable if reported with the proper modifier (commonly modifier 59) and supported by supporting documentation explaining why the edit is irrelevant and payment is merited. 

While a procedure meets the criteria for separate reporting, the modifier, for example, may be used when reporting anesthesia therapy and a post-operative pain procedure. An earlier Timely Topic contains additional examples of employing modifier 59 regarding anesthesia services.

As a result, if necessary, you would report 87150 X2 UOS.87491 (Included in 87150) is used while searching for Chlamydia trachomatis by nucleic acid (DNA or RNA) using an amplified probe method.

CTP code 87591 (included in 87150) is also used to identify Neisseria gonorrhoeae using nucleic acids employing an amplified probe technique (DNA or RNA). Modifier 59 would not apply to either of these codes because 87491 and 87591 are combined into 87150 unless there is specific documentation and a deliberate choice to use modifier 59.

As long as there are no feasible alternatives to integrate higher-level components into STI screening, matching individual factors to screening test indications is the mainstay. According to most experts, screening recommendations can perform when there is enough proof to support the claim that implementing screening test recommendations will result in a markedly decreased infection rate in the population studied.

Example

Suppose high-risk sexual behavior has occurred since the original screening test. In that case, pregnant women who are 24 old at the time of the pregnancy diagnosis should repeat screening in the third trimester.

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