Local Coverage Article Billing and Coding

Billing and Coding: Zika Virus Testing by PCR and ELISA Methods

A55327

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Article Information

General Information

Article ID
A55327
Article Title
Billing and Coding: Zika Virus Testing by PCR and ELISA Methods
Article Type
Billing and Coding
Original Effective Date
10/01/2016
Revision Effective Date
10/01/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

For calendar year 2018 CMS has adopted the new 2018 AMA CPT® codes for Zika virus testing. For dates of service 1/1/2018 and forward providers should bill using these new codes. For dates of service prior to 1/1/2018 the previous instructions will still apply.

Testing for the Zika virus must follow the Food and Drug Administration (FDA) and CDCP guidelines. This article does not address medical necessity but rather proper coding for claims submission.

Claims submissions should utilize the coding instructions below regardless of the specimen source. In the narrative section of the claim form (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form or paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims) please enter the following verbiage (without quotation marks) as it pertains to the respective tests.

For Claims submitted prior to 1/1/2018 use the following guidance:

  1. Zika rRT-PCR only – Use CPT® 87999 and enter “Zika PCR” in the narrative field regardless of the CDCP approved proprietary test utilized*
  2. Trioplex rRT-PCR – Use CPT® 87999 and enter “Zika Trioplex”*
  3.  anti-Zika immunoglobulin (IgM) – Use CPT® 86790 
  4. Dengue rRT-PCR only – use CPT® 87798 
  5. Chikungunya rRT-PCR only - use CPT® 87798
  6. If billing for both Dengue and Chikungunya rRT-PCR – use CPT® 87801 once.

If a plaque reduction neutralization test (PRNT) is indicated, that testing must be conducted by CDC or by a PRNT laboratory designated by CDC to do confirmatory PRNT testing for the Zika response. The claim for PRNT testing is not submitted to Medicare.

Items 1, 2 and 3 above require an FDA Emergency Use Authorization to the respective laboratory. Noridian retains the right to be sent a copy of the respective lab’s EUA upon request.

For claims submitted with dates of service on or after 1/1/2018 use the following instructions:

  1. Zika rRT-PCR only – Use CPT® 87662
  2. Zika virus IgM – Use CPT® 86794 
  3. Dengue rRT-PCR only – use CPT® 87798 
  4. Chikungunya rRT-PCR only - use CPT® 8779
  5. If billing for both Dengue and Chikungunya rRT-PCR – use CPT® 87801 once.

Diagnosis coding should include at least one of the following ICD-10 codes:

Code Description
A92.5 Zika virus disease [effective for DOS on or after October 1, 2016]
B30.9 Viral conjunctivitis, unspecified
M25.50-M25.579 Pain in joint
O09.00-O09.93 Supervision of high risk pregnancy
O28.3 Abnormal ultrasonic finding antenatal screening of mother
O28.4 Abnormal radiological finding on antenatal screening of mother (MRI fetus)
O35.00X1-O35.09X9 Maternal care for (suspected) central nervous system malformation in fetus
R21 Rash and other nonspecific skin eruption
R50.9 Fever, unspecified
Z03.73 Encounter for suspected fetal anomaly ruled out
Z03.79 Encounter for other suspected maternal and fetal conditions ruled out.
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out.
Z33.1 Pregnant state, incidental
Z34.00-Z34.93 Encounter for supervision of normal pregnancy.
Z36.89 Encounter for other specified antenatal screening.



Coding Information

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
86790 ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED
86794 ANTIBODY; ZIKA VIRUS, IGM
87662 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ZIKA VIRUS, AMPLIFIED PROBE TECHNIQUE
87798 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM
87801 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(128 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
A92.5 Zika virus disease
B30.9 Viral conjunctivitis, unspecified
M25.50 Pain in unspecified joint
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.519 Pain in unspecified shoulder
M25.521 Pain in right elbow
M25.522 Pain in left elbow
M25.529 Pain in unspecified elbow
M25.531 Pain in right wrist
M25.532 Pain in left wrist
M25.539 Pain in unspecified wrist
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.559 Pain in unspecified hip
M25.561 Pain in right knee
M25.562 Pain in left knee
M25.569 Pain in unspecified knee
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M25.579 Pain in unspecified ankle and joints of unspecified foot
O09.00 Supervision of pregnancy with history of infertility, unspecified trimester
O09.01 Supervision of pregnancy with history of infertility, first trimester
O09.02 Supervision of pregnancy with history of infertility, second trimester
O09.03 Supervision of pregnancy with history of infertility, third trimester
O09.10 Supervision of pregnancy with history of ectopic pregnancy, unspecified trimester
O09.11 Supervision of pregnancy with history of ectopic pregnancy, first trimester
O09.12 Supervision of pregnancy with history of ectopic pregnancy, second trimester
O09.13 Supervision of pregnancy with history of ectopic pregnancy, third trimester
O09.211 Supervision of pregnancy with history of pre-term labor, first trimester
O09.212 Supervision of pregnancy with history of pre-term labor, second trimester
O09.213 Supervision of pregnancy with history of pre-term labor, third trimester
O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester
O09.291 Supervision of pregnancy with other poor reproductive or obstetric history, first trimester
O09.292 Supervision of pregnancy with other poor reproductive or obstetric history, second trimester
O09.293 Supervision of pregnancy with other poor reproductive or obstetric history, third trimester
O09.299 Supervision of pregnancy with other poor reproductive or obstetric history, unspecified trimester
O09.30 Supervision of pregnancy with insufficient antenatal care, unspecified trimester
O09.31 Supervision of pregnancy with insufficient antenatal care, first trimester
O09.32 Supervision of pregnancy with insufficient antenatal care, second trimester
O09.33 Supervision of pregnancy with insufficient antenatal care, third trimester
O09.40 Supervision of pregnancy with grand multiparity, unspecified trimester
O09.41 Supervision of pregnancy with grand multiparity, first trimester
O09.42 Supervision of pregnancy with grand multiparity, second trimester
O09.43 Supervision of pregnancy with grand multiparity, third trimester
O09.511 Supervision of elderly primigravida, first trimester
O09.512 Supervision of elderly primigravida, second trimester
O09.513 Supervision of elderly primigravida, third trimester
O09.519 Supervision of elderly primigravida, unspecified trimester
O09.521 Supervision of elderly multigravida, first trimester
O09.522 Supervision of elderly multigravida, second trimester
O09.523 Supervision of elderly multigravida, third trimester
O09.529 Supervision of elderly multigravida, unspecified trimester
O09.611 Supervision of young primigravida, first trimester
O09.612 Supervision of young primigravida, second trimester
O09.613 Supervision of young primigravida, third trimester
O09.619 Supervision of young primigravida, unspecified trimester
O09.621 Supervision of young multigravida, first trimester
O09.622 Supervision of young multigravida, second trimester
O09.623 Supervision of young multigravida, third trimester
O09.629 Supervision of young multigravida, unspecified trimester
O09.70 Supervision of high risk pregnancy due to social problems, unspecified trimester
O09.71 Supervision of high risk pregnancy due to social problems, first trimester
O09.72 Supervision of high risk pregnancy due to social problems, second trimester
O09.73 Supervision of high risk pregnancy due to social problems, third trimester
O09.811 Supervision of pregnancy resulting from assisted reproductive technology, first trimester
O09.812 Supervision of pregnancy resulting from assisted reproductive technology, second trimester
O09.813 Supervision of pregnancy resulting from assisted reproductive technology, third trimester
O09.819 Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester
O09.821 Supervision of pregnancy with history of in utero procedure during previous pregnancy, first trimester
O09.822 Supervision of pregnancy with history of in utero procedure during previous pregnancy, second trimester
O09.823 Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester
O09.829 Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester
O09.891 Supervision of other high risk pregnancies, first trimester
O09.892 Supervision of other high risk pregnancies, second trimester
O09.893 Supervision of other high risk pregnancies, third trimester
O09.899 Supervision of other high risk pregnancies, unspecified trimester
O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester
O09.91 Supervision of high risk pregnancy, unspecified, first trimester
O09.92 Supervision of high risk pregnancy, unspecified, second trimester
O09.93 Supervision of high risk pregnancy, unspecified, third trimester
O28.3 Abnormal ultrasonic finding on antenatal screening of mother
O28.4 Abnormal radiological finding on antenatal screening of mother
O35.00X1 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 1
O35.00X2 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 2
O35.00X3 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 3
O35.00X4 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 4
O35.00X5 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 5
O35.00X9 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, other fetus
O35.07X1 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 1
O35.07X2 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 2
O35.07X3 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 3
O35.07X4 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 4
O35.07X5 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 5
O35.07X9 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, other fetus
O35.09X1 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 1
O35.09X2 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 2
O35.09X3 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 3
O35.09X4 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 4
O35.09X5 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 5
O35.09X9 Maternal care for (suspected) other central nervous system malformation or damage in fetus, other fetus
O35.3XX0 Maternal care for (suspected) damage to fetus from viral disease in mother, not applicable or unspecified
O35.3XX1 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 1
O35.3XX2 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 2
O35.3XX3 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 3
O35.3XX4 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 4
O35.3XX5 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 5
O35.3XX9 Maternal care for (suspected) damage to fetus from viral disease in mother, other fetus
R21 Rash and other nonspecific skin eruption
R50.9 Fever, unspecified
Z03.73 Encounter for suspected fetal anomaly ruled out
Z03.79 Encounter for other suspected maternal and fetal conditions ruled out
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
Z20.821 Contact with and (suspected) exposure to Zika virus
Z33.1 Pregnant state, incidental
Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.01 Encounter for supervision of normal first pregnancy, first trimester
Z34.02 Encounter for supervision of normal first pregnancy, second trimester
Z34.03 Encounter for supervision of normal first pregnancy, third trimester
Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester
Z34.81 Encounter for supervision of other normal pregnancy, first trimester
Z34.82 Encounter for supervision of other normal pregnancy, second trimester
Z34.83 Encounter for supervision of other normal pregnancy, third trimester
Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester
Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester
Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester
Z36.89 Encounter for other specified antenatal screening

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
999x Not Applicable

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2022 R10

The following were made to ICD-10-CM Codes that Support Medical Necessity, Group 1:
ICD-10 codes deleted: O35.0XX0; O35.0XX1; O35.0XX2; O35.0XX3; O35.0XX4; O35.0XX5; O35.0XX9

ICD-10 codes added: O3500X1; O3500X2; O3500X3; O3500X4; O3500X5; O3500X9; O3507X1; O3507X2; O3507X3; O3507X4; O3507X5; O3507X9; O3509X1; O3509X2; O3509X3; O3509X4; O3509X5; O3509X9

This revision is due to the annual ICD-10 updates effective 10/1/2022.

10/01/2018 R9

Converted to Billing and Coding article type only. No changes to article content.

10/01/2018 R8

09.05.18: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

The following ICD-10 Codes were added to the ICD-10 Codes that Support Medical Necessity field: Z20.821. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

01/01/2018 R7

2018 CPT Coded added effective 01/01/2018: 86794 and 87662

10/01/2017 R6

08/28/2017: Adding Code Z36.89 to replace deleted code Z36 per ICD-10-Coding Update.

10/01/2016 R5 Removal of language: *The use of modifier -22 is a temporary measure to allow for added payment to help offset the costs of the specific handling requirements of the FDA EUA and CDCP guidance. This exception will expire on March 30, 2017 or when a CPT® or Medicare procedure code is issued or when the FDA EUA is rescinded, whichever is sooner
10/01/2016 R4 Change CPT codes in 1) Zika rRT-PCR only – Use CPT® 87798-22 to 87999 and 2) Trioplex rRT-PCR – Use CPT® 87801-22 to 87999
10/01/2016 R3 To add Part A billing information to Narrative: (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form for paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims)
10/01/2016 R2 Revised to add codes in Group I
10/01/2016 R1 Typographical Error

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Keywords

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