Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87653, 87500, 87481, 87798, 87641-
59, 87640-59) provided April 5, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this claim was not processed according to 
Medicare guidelines. The Plan denied your request. The Plan says there is a more appropriate panel code 87801 
that should have been used. 
 
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, the CPT Code Manual definition of code 87653 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group B, amplified probe technique. The definition of code 87500 is infectious agent 
detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), 
amplified probe technique. The definition of code 87481 is candida species, amplified probe technique. The 
definition of code 87798 is infectious agent detection, by nucleic acid (DNA or RNA), not otherwise specified; 
amplified probe technique. The definition of code 87641 is staphylococcus aureus, methicilian resistant, 
amplified technique. The definition of code 87640 is staphylococcus aureus, amplified technique.  
 
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 the laboratory services. Our reviewer found for code 87653, 
the documentation submitted was reviewed and does not meet criteria. The provider reported procedure code 
with appended modifier 59 distinct procedural service to bypass NCCI Edit with CPT  87801 Infectious agent 
detection, multiple organism. However, the laboratory report does not include documentation to support 
rationale of separately billing procedure code with appended modifier, and therefore, cannot be verified. 
 
For code 87500, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit with code 87801- 
Infectious agent detection, multiple organism. However, the laboratory report does not include documentation 
to support rationale of separately billing procedure code with appended modifier, and therefore, cannot be 
verified. 
 
For code 87481, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit with code 87801- 
Infectious agent detection, multiple organism. However, the laboratory report does not include documentation 
to support rationale of separately billing procedure code with appended modifier, and therefore, cannot be 
verified. 
 
For code 87798, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit with code 87801- 
Infectious agent detection, multiple organism. However, the laboratory report does not include documentation 
to support rationale of separately billing procedure code with appended modifier, and therefore, cannot be 
verified. 
 
For code 87641, the documentation submitted was reviewed and does not meet criteria. The provider reported 
procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit with code 87801 - 
Infectious agent detection, multiple organism. However, the laboratory report does not include documentation 
to support rationale of separately billing procedure code with appended modifier, and therefore, cannot be 
verified. 
 
For code 87640, the documentation submitted was reviewed and does not meet criteria. The provider reported procedure code with appended modifier 59 distinct procedural service to bypass NCCI Edit with code 87640 - 
Staphylococcus aureus, methicilian resistant, amplified technique. However, the laboratory report does not 
include documentation to support rationale of separately billing procedure code with appended modifier, and 
therefore, 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87653, 87500, 87481, 87798, 87641-59, 87640-59) provided 
April 5, 2023.