Can CPT Code 87491 and 87591 Be Billed Together?
Understand medical billing for specific diagnostic tests. Learn CPT code rules, NCCI edits, and essential documentation for proper reimbursement.
Current Procedural Terminology (CPT) codes standardize medical procedures and services for healthcare billing and reimbursement. Understanding their correct application is essential for accurate financial operations. This article clarifies specific billing considerations for CPT codes 87491 and 87591, particularly when both are performed for the same patient.
Understanding the Diagnostic Tests
CPT code 87491 identifies infectious agent detection by nucleic acid for Chlamydia trachomatis using an amplified probe technique. CPT code 87591 represents infectious agent detection by nucleic acid for Neisseria gonorrhoeae, also via an amplified probe technique. Both are molecular diagnostic tests, detecting the genetic material of specific bacteria. These techniques offer high sensitivity and specificity for identifying these infectious agents.
Chlamydia trachomatis and Neisseria gonorrhoeae are prevalent bacterial sexually transmitted infections (STIs). These infections frequently present with overlapping clinical symptoms, and co-infection is common. Many diagnosed with gonorrhea are also co-infected with chlamydia, and vice versa. Due to this high co-occurrence, healthcare providers often test for both simultaneously to ensure comprehensive diagnosis and appropriate treatment.
Rules for Billing Multiple Molecular Tests
Billing for multiple CPT codes is governed by specific guidelines. The National Correct Coding Initiative (NCCI) edits, developed by the Centers for Medicare and Medicaid Services (CMS), determine which code pairs can be billed together. These edits include Procedure-to-Procedure (PTP) edits, which identify code combinations not typically reported together. NCCI edits are updated to reflect changes in medical practice and coding standards.
When CPT codes 87491 and 87591 are performed on the same patient on the same date of service, many payers implement specific bundling policies. Rather than allowing separate billing, these payers often bundle both tests into a single, more comprehensive CPT code, 87801. CPT code 87801 is described as “Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique.” Even if individual codes 87491 and 87591 are submitted, the claim may be adjusted to reimburse only for 87801.
The concept of “unbundling” typically involves applying modifiers, such as Modifier -59 (Distinct Procedural Service), to indicate separate services. Modifier -59 is used to bypass NCCI edits under specific, documented circumstances. However, for 87491 and 87591, many payer policies explicitly state that no modifiers will override their internal bundling logic to CPT code 87801. Providers should consult individual payer policies for concurrent billing requirements, as their bundling rules may supersede general NCCI modifier guidelines.
Essential Documentation for Reimbursement
Comprehensive medical documentation is essential for appropriate reimbursement for diagnostic tests like CPT codes 87491 and 87591, and for navigating potential audits. Payers require clear evidence that services were medically necessary and appropriately ordered. Without supporting documentation, claims may face denials or recoupments during review processes.
The patient’s medical record must contain specific details to justify test performance and billing. This includes a clear and signed order from the treating physician, or documentation indicating the physician’s intent to order the tests. General statements like “run labs” are insufficient; specific tests must be noted. Documentation should also detail the patient’s symptoms, relevant risk factors, and the clinical indications that necessitated testing for both Chlamydia trachomatis and Neisseria gonorrhoeae.
The medical record must include test results. Accurate diagnosis codes (ICD-10-CM codes) that correlate with the patient’s condition and support medical necessity should be documented. Maintaining thorough and accurate records is a proactive measure against billing compliance audits, which frequently scrutinize laboratory services for adherence to Medicare and other payer guidelines. Insufficient documentation is a primary reason for payment errors identified during these audits.