Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 87481 and 87640. We decided that the Plan does not 
have to pay for procedure code 87798.  
 
You asked the Plan to pay for procedure codes 87481, 87640 and 87798 billed for date of service August 18, 
2023. You say that you have billed the services at issue correctly. The Plan says that payment for codes 87481, 
87640 and 87798 is bundled into payment for code 87801. 
 
We decided that the Plan has to pay for procedure codes 87481 and 87640.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
87481 and 87640 are column II codes to column I codes 87801; however, 87481 and 87640 were billed with a 
modifier. 
 
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 codes 87481 and 87640. Our reviewer says that codes 87481 
and 87640 meet criteria for payment in this case. Our reviewer found that the parenthetical guidance for 87801 
states that the code is used to report multiple agents tested for with a single result, and specific organisms 
should be reported with their own codes, which allows 87481 and 87640 to be reported with bypass modifier 
59. Codes 87481 and 87640 are supported as separate and distinct services. The record shows that candida 
species were tested for and were negative. The record shows that staph aureus was tested for and was negative. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 87481 and 87640 have been met. Therefore, we decided that the Plan has 
to pay for procedure codes 87481 and 87640.  
 
We also decided that the Plan does not have to pay for procedure code 87798. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we have confirmed that code 87798 is a column II code to column I code 87801; however, 87798 
was billed with a modifier.  
 
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 code 87798. Our reviewer says that code 87798 does not 
meet criteria for payment in this case. Our reviewer found that code 87798 is not supported. The record does 
not state which "not otherwise specified" organisms were tested for. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 87798 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 87798. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.