LCD Reference Article Billing and Coding Article

Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)

A56642

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56642
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)
Article Type
Billing and Coding
Original Effective Date
12/30/2019
Revision Effective Date
04/01/2023
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Internet Only Manual (IOM) Citations:

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure Codes and Section 20.9 National Correct Coding Initiative (NCCI)

National Correct Coding Initiative (NCCI) Citation:

  • NCCI Policy Manual for Medicare Services,
    • Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services
    • Chapter 10 Pathology/Laboratory Services CPT codes 80000-89999 For National Correct Coding Initiative Policy Manual for Medicare Services

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text


This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38229 Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

A GIP test panel is a single service with a single unit of service (UOS=1). A GIP test panel must not be unbundled and billed as individual components regardless of the fact that the GIP test panel reports multiple individual pathogens and/or targets.

Utilization Parameters

Medicare will allow reporting only one GIP multiplex panel (CPT codes 0369U, 87505, 87506, and 87507) summing the testing for all targets per day per beneficiary by the same or different provider consistent with the related LCD.

Consistent with the LCD, repeat NAAT testing within seven days during the same episode of diarrhea will be denied (any combination of CPT codes 0369U, 87505, 87506, and 87507).

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description

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N/A

Revenue Codes

Code Description

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N/A

CPT/HCPCS Codes

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N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT codes: 87505 and 87506.

Group 1 Codes
Code Description
R19.7 Diarrhea, unspecified

Group 2

(1 Code)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT codes: 0369U and 87507.

Group 2 Codes
Code Description
R19.7* Diarrhea, unspecified
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Note: Dual Diagnosis: When reporting ICD-10-CM code R19.7, one of the immunosuppression diagnosis codes listed in Table 3 below must also be reported.

Group 3

(59 Codes)
Group 3 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Note: None of the diagnosis codes listed in Table 3 are stand-alone diagnosis codes.

Group 3 (Immunosuppression diagnosis codes – secondary codes to be reported with those in Group 2)

Group 3 Codes
Code Description
B20 Human immunodeficiency virus [HIV] disease
D80.0 Hereditary hypogammaglobulinemia
D80.1 Nonfamilial hypogammaglobulinemia
D80.2 Selective deficiency of immunoglobulin A [IgA]
D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses
D80.4 Selective deficiency of immunoglobulin M [IgM]
D80.5 Immunodeficiency with increased immunoglobulin M [IgM]
D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia
D80.8 Other immunodeficiencies with predominantly antibody defects
D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis
D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers
D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers
D81.31 Severe combined immunodeficiency due to adenosine deaminase deficiency
D81.4 Nezelof's syndrome
D81.5 Purine nucleoside phosphorylase [PNP] deficiency
D81.6 Major histocompatibility complex class I deficiency
D81.7 Major histocompatibility complex class II deficiency
D81.810 Biotinidase deficiency
D81.818 Other biotin-dependent carboxylase deficiency
D81.89 Other combined immunodeficiencies
D82.0 Wiskott-Aldrich syndrome
D82.1 Di George's syndrome
D82.2 Immunodeficiency with short-limbed stature
D82.3 Immunodeficiency following hereditary defective response to Epstein-Barr virus
D82.4 Hyperimmunoglobulin E [IgE] syndrome
D82.8 Immunodeficiency associated with other specified major defects
D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders
D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells
D83.8 Other common variable immunodeficiencies
D84.0 Lymphocyte function antigen-1 [LFA-1] defect
D84.1 Defects in the complement system
D84.81 Immunodeficiency due to conditions classified elsewhere
D84.821 Immunodeficiency due to drugs
D84.822 Immunodeficiency due to external causes
D84.89 Other immunodeficiencies
D89.0 Polyclonal hypergammaglobulinemia
D89.1 Cryoglobulinemia
D89.3 Immune reconstitution syndrome
D89.41 Monoclonal mast cell activation syndrome
D89.42 Idiopathic mast cell activation syndrome
D89.43 Secondary mast cell activation
D89.49 Other mast cell activation disorder
D89.810 Acute graft-versus-host disease
D89.811 Chronic graft-versus-host disease
D89.812 Acute on chronic graft-versus-host disease
D89.82 Autoimmune lymphoproliferative syndrome [ALPS]
D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified
Z94.0 Kidney transplant status
Z94.1 Heart transplant status
Z94.2 Lung transplant status
Z94.3 Heart and lungs transplant status
Z94.4 Liver transplant status
Z94.5 Skin transplant status
Z94.6 Bone transplant status
Z94.81 Bone marrow transplant status
Z94.82 Intestine transplant status
Z94.83 Pancreas transplant status
Z94.84 Stem cells transplant status
N/A

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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Additional ICD-10 Information

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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.

Code Description

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N/A

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.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/01/2023 R5

Article revised and published on 04/20/2023 effective for dates of service on and after 04/01/2023 to reflect the April Quarterly CPT/HCPCS Code Update. CPT code ‘0369U’ was added to the 'Article Text/Utilization Parameters', ‘CPT/HCPCS Codes Group 2’ and ‘ICD-10-CM Codes that Support Medical Necessity/Group 2 Paragraph’.

10/16/2022 R4

Article effective for dates of service on and after 10/16/2022.

Draft article posted 04/14/2022.

04/01/2022 R3

Article revised and published on 05/05/2022 effective for dates of service on and after 04/01/2022 to reflect the April Quarterly CPT/HCPCS Code Update. The following HCPCS code was removed from the 'Utilization Parameters', the ‘Group 1 Codes’ and the ‘ICD-10-CM Codes that Support Medical Necessity/Group 1 and Group 2 Paragraph' sections: 0097U. The ‘ICD-10-CM Codes that Support Medical Necessity’ section for the ‘Group 2 Codes’ and the associated asterisk note were revised for clarification.

12/30/2019 R2

Article revised and published on 8/13/2020 effective for dates of service on and after 12/30/2019 in response to an external request. CPT Code Group 2 has been combined with CPT Code Group 1 and the ICD-10 Code Group 2 Paragraph and Codes were removed. The prior ICD-10 Code Group 3 is now Group 2. In addition, the paragraph related to the NCCI edits and manual has been removed and minor formatting changes have been made.

12/30/2019 R1

Future billing and coding Article related to L38229, Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) published on November 14, 2019 and will become effective on December 30, 2019.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Public Versions
Updated On Effective Dates Status
04/14/2023 04/01/2023 - N/A Currently in Effect You are here
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