Article - Billing and Coding: CPT Code 87641 (Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique) (A52379)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations:42 CFR Sections 409 et al include the Medicare Program Prospective Payment System for Hospital Outpatient Services Final Rule published in the FR Vol. 65, No. 68, April 7, 2000.CMS Publications:CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 1:6060.1.1 Required Hospital Notice to BeneficiariesArticle TextThe purpose of this article is to alert providers that National Government Services considers CPT code 87641 to be a test used for screening purposes for which payment will not be allowed.Screening tests are statutorily non-covered based on Title VIII of the Social Security Act, Section 1862(a)(1)(A) which excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Background:Methicillin-resistant S. aureus (MRSA) was first described in 1961 and now constitutes more than 50% of S. aureus isolates that cause infections in the hospital setting.The worldwide emergence of MRSA is mainly the result of the extensive spread of a limited number of strains in hospitals, which are high risk settings for MRSA infection.Staphyloccocus aureusis an opportunistic pathogen that mainly infects patients who have had surgery or who have invasive devices (such as intravascular catheters). The epidemiology of MRSA has changed recently infections are no longer confined to the hospital setting, but also appear in healthy people in the community with no established risk factors for acquiring MRSA. These community associated MRSA strains differ from hospital associated strains. Most carriers ofS aureus, both hospital inpatients and others, are healthy asymptomatic people without evident infection. In hospitals where MRSA is endemic, patients risk being colonized by spread from other patients or healthcare workers. Colonization withS aureusin hospital is a risk factor for subsequent infection. (Kluytmans J, 2009).CPT code 87641 was established to report methicillin resistant Staphylococcus aureus (MRSA) by amplified probe technique and it is used to bill for assays that detect methicillin resistance and identify Staphylococcus aureus using a single nucleic acid sequence." (CPT Changes 2007  An Insiders View)The availability of nucleic acid probes has permitted the rapid direct identification of microorganisms DNA or RNA. Amplification techniques, including, but not limited to the polymerase chain reaction (PCR), results in the doubling of copies of specified target DNA with each round of amplification, eventually resulting in millionfold levels of amplification. The product of the amplification (i.e., DNA) is then detected using a variety of techniques. (Blue Cross & Blue Shield of Mississippi. Identification of Microorganisms Using Nucleic Acid Probes)Although some hospitals are screening patients prior to inpatient or outpatient hospitalization to identify carriers of methicillin resistant Staphylococcus aureus as an infection control measure, additional research will be required to demonstrate whether the use of universal rapid MRSA admission screening will reduce nosocomial MRSA infection in hospitals compared to the use of alternative control measures against MRSA.Screening tests are statutorily non-covered based on Title VIII of the Social Security Act, Section 1862(a)(1)(A) which excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. This purpose of this article is to alert providers that National Government Services considers CPT code 87641 to be a test used for screening purposes for which payment will not be allowed.Specific Coding Guideline:Claims for CPT Code 87641 (Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique) services are not payable under Medicare Part B for screening purposes and will be denied.When billing CPT code 87641 for screening purposes (statutorily non-covered), ICD-10-CM codes, including but not limited to those listed below, may be reported. The GY modifier should be reported, as applicable.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.