Question:

Please advise how hospital laboratories can be paid for outpatient susceptibility studies (CPT® 87181–87190) for positive cultures. This is an issue due to medical necessity; however, the provider doesn’t have a diagnosis at the time of the order. This is not paid if the organism is not identified. Most laboratories automatically perform this test as part of routine culture work-ups.

Answer:

Unfortunately, when medical necessity is not met (e.g., covered diagnosis), the hospital laboratory cannot expect to be reimbursed. Most national reference laboratories have policies for reflex testing (e.g., susceptibility studies) when an isolate is positively identified from the culture.

Make sure your laboratory has clear policies for reflex testing that include a physician inquiry when the order does not indicate reflex test for positive cultures only or decline performance of the reflex test when the culture returns negative or when the physician does not provide an applicable diagnosis. Some hospital laboratories have implemented policies that any non-covered test will be at the expense of the ordering provider.


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This question was answered in an edition of our Laboratory Compliance Manager. For more hot topics relating to laboratory services, please view our store, or call us at 1.800.252.1578 ext. 2.

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.