Retired Local Coverage Article Billing and Coding

Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)

A56711

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Contractor Information

Article Information

General Information

Article ID
A56711
Article Title
Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs)
Article Type
Billing and Coding
Original Effective Date
07/01/2019
Revision Effective Date
11/08/2021
Revision Ending Date
06/01/2022
Retirement Date
06/01/2022
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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B Mac (B) Contacts With Independent Clinical Laboratories

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §50.5 Jurisdiction of Laboratory Claims, §60.1.2 Independent Laboratory Specimen Drawing, §60.2 Travel Allowance

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §10 Reporting ICD Diagnosis and Procedure Codes

 

 

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs).

This contractor will provide limited coverage for Gastrointestinal Pathogen (GIP) molecular assays identified by multiplex nucleic acid amplification tests (NAATs). In immune competent beneficiaries, coverage is limited to no more than 5 bacterial targets (when not testing for clostridium difficile). Testing for 6-11 pathogens is covered when there is a clinical concern for clostridium difficile colitis, and clostridium difficile is one of the pathogens being tested.

Testing for 12 or more organisms will only be covered in critically ill or immunosuppressed patients. This contractor expects that critically ill patients must be tested and managed in the appropriate inpatient facility. As such, for critically ill patients or immunosuppressed patients requiring these tests only Part A claims should be submitted.

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

Any diagnosis submitted must have documentation in the patient’s record to support coverage and medical necessity.

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.

Billing and Coding Information:

To bill for GIP molecular assays identified by multiplex NAATs, please provide the following claim information:

  • If the panel being used does not have its own proprietary CPT code, use CPT code 87505, 87506 or 87507
  • For dates of service on or after 7/1/2019, laboratories billing for services using the BioFire® FilmArray® Gastrointestinal (GI) Panel (BioFire® Diagnostics) should report 0097U
  • Enter 1 unit of service (UOS)
  • Enter the appropriate CPT code in the comment/narrative field for the following Part B claim field/types:
    • Loop 2400 or SV101-7 for the 5010A1 837P
    • Item 19 for paper claim
  • Enter the appropriate CPT code in the comment/narrative field for the following Part A claim field/types:
    • Line SV202-7 for 837I electronic claim
    • Block 80 for the UB04 claim form
  • ICD-10-CM diagnosis code(s) as set forth below.

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

These codes are covered

Group 1 Codes
CodeDescription
87505 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 3-5 TARGETS
87506 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 6-11 TARGETS

Group 2

(2 Codes)
Group 2 Paragraph

This code is covered in beneficiaries with immunodeficiency and/or critical illness

Group 2 Codes
CodeDescription
87507 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 12-25 TARGETS
0097U GASTROINTESTINAL PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 22 TARGETS (CAMPYLOBACTER [C. JEJUNI/C. COLI/C. UPSALIENSIS], CLOSTRIDIUM DIFFICILE [C. DIFFICILE] TOXIN A/B, PLESIOMONAS SHIGELLOIDES, SALMONELLA, VIBRIO [V. PARAHAEMOLYTICUS/V. VULNIFICUS/V. CHOLERAE], INCLUDING SPECIFIC IDENTIFICATION OF VIBRIO CHOLERAE, YERSINIA ENTEROCOLITICA, ENTEROAGGREGATIVE ESCHERICHIA COLI [EAEC], ENTEROPATHOGENIC ESCHERICHIA COLI [EPEC], ENTEROTOXIGENIC ESCHERICHIA COLI [ETEC] LT/ST, SHIGA-LIKE TOXIN-PRODUCING ESCHERICHIA COLI [STEC] STX1/STX2 [INCLUDING SPECIFIC IDENTIFICATION OF THE E. COLI O157 SEROGROUP WITHIN STEC], SHIGELLA/ENTEROINVASIVE SCHERICHIA COLI [EIEC], CRYPTOSPORIDIUM, CYCLOSPORA CAYETANENSIS, ENTAMOEBA HISTOLYTICA, GIARDIA LAMBLIA [ALSO KNOWN AS G. INTESTINALIS AND G. DUODENALIS], ADENOVIRUS F 40/41, ASTROVIRUS, NOROVIRUS GI/GII, ROTAVIRUS A, SAPOVIRUS [GENOGROUPS I, II, IV, AND V])

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(49 Codes)
Group 1 Paragraph

One of the following diagnosis codes must be on the claim to bill for 87505 or 87506. 

Group 1 Codes
CodeDescription
A00.0 Cholera due to Vibrio cholerae 01, biovar cholerae
A00.1 Cholera due to Vibrio cholerae 01, biovar eltor
A00.9 Cholera, unspecified
A01.00 Typhoid fever, unspecified
A01.09 Typhoid fever with other complications
A01.1 Paratyphoid fever A
A01.2 Paratyphoid fever B
A01.3 Paratyphoid fever C
A02.0 Salmonella enteritis
A02.8 Other specified salmonella infections
A03.0 Shigellosis due to Shigella dysenteriae
A03.1 Shigellosis due to Shigella flexneri
A03.2 Shigellosis due to Shigella boydii
A03.3 Shigellosis due to Shigella sonnei
A03.8 Other shigellosis
A04.0 Enteropathogenic Escherichia coli infection
A04.1 Enterotoxigenic Escherichia coli infection
A04.2 Enteroinvasive Escherichia coli infection
A04.3 Enterohemorrhagic Escherichia coli infection
A04.5 Campylobacter enteritis
A04.6 Enteritis due to Yersinia enterocolitica
A04.71 Enterocolitis due to Clostridium difficile, recurrent
A04.72 Enterocolitis due to Clostridium difficile, not specified as recurrent
A04.8 Other specified bacterial intestinal infections
A04.9 Bacterial intestinal infection, unspecified
A05.0 Foodborne staphylococcal intoxication
A05.1 Botulism food poisoning
A05.2 Foodborne Clostridium perfringens [Clostridium welchii] intoxication
A05.3 Foodborne Vibrio parahaemolyticus intoxication
A05.4 Foodborne Bacillus cereus intoxication
A05.5 Foodborne Vibrio vulnificus intoxication
A06.0 Acute amebic dysentery
A06.1 Chronic intestinal amebiasis
A06.2 Amebic nondysenteric colitis
A07.1 Giardiasis [lambliasis]
A07.2 Cryptosporidiosis
A07.4 Cyclosporiasis
A08.0 Rotaviral enteritis
A08.11 Acute gastroenteropathy due to Norwalk agent
A08.2 Adenoviral enteritis
A08.32 Astrovirus enteritis
A09 Infectious gastroenteritis and colitis, unspecified
A32.11 Listerial meningitis
A32.12 Listerial meningoencephalitis
A32.7 Listerial sepsis
K56.0 Paralytic ileus
M31.19 Other thrombotic microangiopathy
R10.0 Acute abdomen
R19.7 Diarrhea, unspecified

Group 2

(91 Codes)
Group 2 Paragraph

For immunosuppressed patients, to bill for 87507 or 0097U, an ICD-10 diagnosis code from Group 2 must be on the claim in addition to an ICD-10 diagnosis code from Group 1.

Group 2 Codes
CodeDescription
A41.9 Sepsis, unspecified organism
B20 Human immunodeficiency virus [HIV] disease
D61.09 Other constitutional aplastic anemia
D61.1 Drug-induced aplastic anemia
D61.2 Aplastic anemia due to other external agents
D61.3 Idiopathic aplastic anemia
D61.810 Antineoplastic chemotherapy induced pancytopenia
D61.811 Other drug-induced pancytopenia
D61.818 Other pancytopenia
D61.82 Myelophthisis
D61.89 Other specified aplastic anemias and other bone marrow failure syndromes
D61.9 Aplastic anemia, unspecified
D64.81 Anemia due to antineoplastic chemotherapy
D64.89 Other specified anemias
D70.0 Congenital agranulocytosis
D70.1 Agranulocytosis secondary to cancer chemotherapy
D70.2 Other drug-induced agranulocytosis
D70.3 Neutropenia due to infection
D70.4 Cyclic neutropenia
D70.9 Neutropenia, unspecified
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
D80.9 Immunodeficiency with predominantly antibody defects, unspecified
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
D81.30 Adenosine deaminase deficiency, unspecified
D81.31 Severe combined immunodeficiency due to adenosine deaminase deficiency
D81.32 Adenosine deaminase 2 deficiency
D81.39 Other 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
D81.9 Combined immunodeficiency, unspecified
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
D83.9 Common variable immunodeficiency, unspecified
D84.0 Lymphocyte function antigen-1 [LFA-1] defect
D84.1 Defects in the complement system
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
D89.44 Hereditary alpha tryptasemia
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
D89.813 Graft-versus-host disease, unspecified
D89.82 Autoimmune lymphoproliferative syndrome [ALPS]
D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
T80.82XS Complication of immune effector cellular therapy, sequela
Z92.850 Personal history of Chimeric Antigen Receptor T-cell therapy
Z92.858 Personal history of other cellular therapy
Z92.86 Personal history of gene therapy
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

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

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


N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
06/01/2022 R6

This article is being retired because the information in this article has been incorporated within the Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing A58726 article.

11/08/2021 R5

Effective 08/05/2021: Revision history update to reflect the removal of DX codes D89.831, D89.832, D89.833, D89.834, D89.835, D89.839 from ICD-10 Codes that Support Medical Necessity Group 1: Codes on the 11/08/2021 revision.

11/08/2021 R4

Effective 11/08/2021: Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added A41.9. R65.20, and R65.21.

Effective 10/21/2021: Under Article Text added “This contractor expects that critically ill patients will be tested and managed in the appropriate inpatient facility. As such, for critically ill patients, only Part A claims should be submitted.” Under CPT/HCPCS Codes Group 2: Paragraph revised to “This code is covered in beneficiaries with immunodeficiency AND/OR critical illness.” Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph revised to “For immunosuppressed patients, to bill for 87507 or 0097U, an ICD-10 diagnosis code from Group 2 must be on the claim in addition to an ICD-10 diagnosis code from Group 1.” Under ICD-10 Codes that Support Medical Necessity Group 2: Codes deleted A04.9, A09, K56.0, R10.0, and R19.7.

Effective 10/01/2021: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added M31.19. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added D89.44, T80.82XS, Z92.850, Z92.858, and Z92.86. This revision is due to the Annual ICD-10 Code Update and is effective on 10/1/2021.

Effective 08/05/2021: Under CMS National Coverage Policy removed regulation CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 §80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests. Added regulation CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories. Under CPT/HCPCS Codes Group 1: Codes moved 0097U from Group 1 codes to Group 2 codes. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph deleted 0097U. Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added A00.0, A00.1, A00.9, A01.09, A01.1, A01.2, A01.3, A02.8, A05.4, A05.5, A06.0, A06.1, A06.2, A07.1, A07.2, A07.4, A08.0, A08.11, A08.2, A08.32, A32.11, A32.12, A32.7, K56.0, and R10.0. Deleted A02.9, B20, D80.0, D80.1, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D80.8, D80.9, D81.0, D81.1, D81.2, D81.30, D81.31, D81.32, D81.39, D81.4, D81.5, D81.6, D81.7, D81.810, D81.818, D81.819, D81.89, D81.9, D82.0, D82.1, D82.2, D82.3, D82.4, D82.8, D82.9, D83.0, D83.1, D83.2, D83.8, D83.9, D84.0, D84.1, D84.89, D84.9, D89.0, D89.1, D89.2, D89.3, D89.40, D89.41, D89.42, D89.43, D89.49, D89.810, D89.811, D89.812, D89.813, D89.82, D89.89, D89.9, Y92.239, Z94.0, Z94.1, Z94.2, Z94.3, Z94.4, Z94.5, Z94.6, Z94.81, Z94.82, Z94.83, and Z94.84. Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph revised to “To bill for 87507 or 0097U, an ICD-10 diagnosis code from Group 2 must be on the claim in addition to an ICD-10 diagnosis code from Group 1”. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added A04.9, A09, D61.09, D61.1, D61.2, D61.3, D61.810, D61.811, D61.818, D61.82, D61.89, D61.9, D64.81, D64.89, D70.0, D70.1, D70.2, D70.3, D70.4, D70.9, D84.821, D84.822, K56.0, R10.0, and R19.7. Deleted D80.7, D81.819, D82.9, D84.9, D89.2, D89.40, D89.9, and Y92.239. Formatting, punctuation, and typographical errors were corrected throughout the article.

10/01/2020 R3

10/01/2020: Under ICD-10 Codes that support Medical Necessity Group I Coding added: D84.89; D89.831; D89.832; D89.833; D89.834; D89.835; D89.839
Group II Update added: D84.89; D89.831;D89.832; D89.833; D89.834; D89.835; D89.839
Deleted Codes: D84.8
These revisions are due to the Annual ICD-10 Updates and become effective on 10/1/2020.

10/01/2019 R2

10/01/2019: This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of the related Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) LCD and placed in this article. CPT® was inserted throughout the article where applicable.

10/01/2019 R1

10/01/2019:

Covered ICD-10 Codes Group 1: Codes ICD-10 code D81.3 was deleted and ICD-10 codes D81.30, D81.31, D81.32, and D81.39 were added.

Covered ICD-10 Codes Group 2: Codes ICD-10 code D81.3 was deleted and ICD- 10 codes D81.30, D81.31, D81.32, and D81.39 were added.

This revision is due to the 2019 Annual ICD-10 Code Update and is effective on October 1, 2019.

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