Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87150, 87481, 87640, 87641, 87653, 87798 
and 87801 billed for date of service April 6, 2021. 
 
You asked the Plan to pay for procedure codes 87150, 87481, 87640, 87641, 87653, 87798 and 87801. You say 
that these services were billed appropriately. The Plan denied your request. The Plan says the payment for these 
services is bundled into the payment for other services billed on this date. Although these services were billed 
with a modifier for separate payment, the records do not support the use of this modifier in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for procedure codes 87150, 87481, 87640, 87641, 87653, 87798 
and 87801. Our reviewer says that payment for codes 87150, 87481, 87640, 87641, 87653, 87798 and 87801 is 
not supported in the medical record. Our reviewer found for code 87150, the laboratory report describes urinary 
tract infection panel including antibiotic resistance markers performed on a clean catch urine specimen. In this 
case, CPT 87150 would be inclusive to CPT 87500, therefore CPT 87150 cannot be verified. For code 87481, 
the laboratory report describes urinary tract infection panel including antibiotic resistance markers performed 
on a clean catch urine specimen. In this case, CPT 87481 would be inclusive to CPT 87801 (multiple 
organisms). For code 87640, the laboratory report describes urinary tract infection panel including antibiotic 
resistance markers performed on a clean catch urine specimen. In this case, CPT 87640 would be inclusive to 
CPT 87801 as well as CPT 87641 (multiple organisms). For code 87641, the laboratory report describes 
urinary tract infection panel including antibiotic resistance markers performed on a clean catch urine 
specimen.  In this case, CPT 87641 would be inclusive to CPT 87801 (multiple organisms). For code 87653, 
the laboratory report describes urinary tract infection panel including antibiotic resistance markers performed 
on a clean catch urine specimen. In this case, CPT 87653 would be inclusive to CPT 87801 (multiple 
organisms). For code 87798, the laboratory report describes urinary tract infection panel including antibiotic 
resistance markers performed on a clean catch urine specimen. In this case, CPT 87798 (each organism) would 
be inclusive to CPT 87801 (multiple organisms). For code 87801, the laboratory report describes urinary tract 
infection panel including antibiotic resistance markers performed on a clean catch urine specimen.  In this case, 
the laboratory report does not specify the organisms, and therefore this procedure cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87150, 87481, 87640, 87641, 87653, 87798 and 87801 have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 87150, 87481, 
87640, 87641, 87653, 87798 and 87801 billed for date of service April 6, 2021.