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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 5 Gynecological Health Services : 5.9 Assays for the Diagnosis of Vaginitis

5.9
Vaginitis assay procedure codes 87480, 87510, 87660, 87661, 87797, and 87800 are benefits of Texas Medicaid.
If more than one of procedure code 87480, 87510, 87660, 87661, or 87800 is submitted by the same provider for the same client with the same date of service, all of the procedure codes are denied. Only one procedure code (87480, 87510, 87660, 87661, or 87800) may be submitted for reimbursement, and providers must submit the most appropriate procedure code for the test provided:
Single organism test. A single test must be submitted for reimbursement using the appropriate procedure code (87480, 87510, 87660, or 87661) that describes the organism being isolated.
Multiple organism test. When testing for multiple vaginal pathogens, providers must submit procedure code 87800 for reimbursement. Procedure code 87800 is inclusive of procedure codes 87480, 87510, 87660, and 87661 and is the most appropriate code to request reimbursement for multiple tests.
If the claim is denied because more than one procedure code was submitted with the same date of service, the provider must appeal the denied claim with a statement indicating which procedure code is most appropriate and should be considered for reimbursement. Procedure codes 87800, 87480, 87510, 87660, and 87661 should not be submitted for reimbursement by the same provider with the same date of service for the same client on the same claim form or on separate claim forms.
Providers are reminded to code to the highest level of specificity with a diagnosis to support medical necessity when submitting procedure code 87797.
Claims may be subject to retrospective review if they are submitted with diagnosis codes that do not support medical necessity.
If a positive test result was not treated, documentation must be present indicating why treatment was not rendered.

Texas Medicaid & Healthcare Partnership
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