Retired Local Coverage Article Billing and Coding

Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels

A57340

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Contractor Information

Article Information

General Information

Article ID
A57340
Article Title
Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels
Article Type
Billing and Coding
Original Effective Date
10/01/2019
Revision Effective Date
02/03/2022
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 which lacks the necessary information to process the claim. 

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.0, 80.1.1, 80.2. Clinical Laboratory services.

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 following coding and billing guidance is to be used with its associated Local Coverage determination.

To report a multiplex PCR respiratory viral panel service, please submit the following claim information:

  • If the panel being used does not have its own proprietary CPT® code, select the appropriate CPT® code.
  • If the test does have a PLA code then submit the appropriate code.
  • Per the MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels LCD, tests that include more than 5 viral pathogens are non-covered. Included in this are 87632, 87633, and additional PLA codes listed in the CPT/HCPCS Codes Group 2: Codes section of this Billing and Coding article.
  • Enter 1 unit of service (UOS)
  • Select the appropriate ICD-10-CM code

A DEX Z-Code™ identifier is not required for multiplex PCR respiratory viral panel testing. If submitting a DEX Z-Code™ identifier, please submit following the below instructions:

  • Enter the appropriate DEX Z-Code™ identifier adjacent to the 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 DEX Z-Code™ identifier adjacent to the 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

Coding Information

CPT/HCPCS Codes

Group 1

(5 Codes)
Group 1 Paragraph

Covered under limited circumstances.

During the Federally designated public health emergency (PHE), the following place of service (POS) codes may be billed: 05, 06, 07, 08, 11, 17, 19, 20, 21, 22, 23, 24, 26, 49, 50, 71, 72, 81.

The following paragraph does not apply during the PHE:

Outside of one of these places of service, these tests must be ordered by an infectious disease specialist who is diagnosing and treating the beneficiary. An exception may be made in geographic locations where no infectious disease specialist can be reasonably reached by the beneficiary and the ordering provider is located closer to the beneficiary's place of residence than the nearest infectious disease specialist. We would generally expect that beneficiaries for whom the test is ordered under this exception to be living in rural locations, islands, or some other location where access to care is limited.

Group 1 Codes
CodeDescription
87631 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 3-5 TARGETS
87636 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) AND INFLUENZA VIRUS TYPES A AND B, MULTIPLEX AMPLIFIED PROBE TECHNIQUE
87637 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), INFLUENZA VIRUS TYPES A AND B, AND RESPIRATORY SYNCYTIAL VIRUS, MULTIPLEX AMPLIFIED PROBE TECHNIQUE
0240U INFECTIOUS DISEASE (VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC RNA, 3 TARGETS (SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 [SARS-COV-2], INFLUENZA A, INFLUENZA B), UPPER RESPIRATORY SPECIMEN, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED
0241U INFECTIOUS DISEASE (VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC RNA, 4 TARGETS (SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 [SARS-COV-2], INFLUENZA A, INFLUENZA B, RESPIRATORY SYNCYTIAL VIRUS [RSV]), UPPER RESPIRATORY SPECIMEN, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED

Group 2

(7 Codes)
Group 2 Paragraph

These codes are non-covered.

Group 2 Codes
CodeDescription
87632 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 6-11 TARGETS
87633 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 12-25 TARGETS
0115U RESPIRATORY INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), 18 VIRAL TYPES AND SUBTYPES AND 2 BACTERIAL TARGETS, AMPLIFIED PROBE TECHNIQUE, INCLUDING MULTIPLEX REVERSE TRANSCRIPTION FOR RNA TARGETS, EACH ANALYTE REPORTED AS DETECTED OR NOT DETECTED
0151U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN SPECIFIC NUCLEIC ACID (DNA OR RNA), 33 TARGETS, REAL-TIME SEMI-QUANTITATIVE PCR, BRONCHOALVEOLAR LAVAGE, SPUTUM, OR ENDOTRACHEAL ASPIRATE, DETECTION OF 33 ORGANISMAL AND ANTIBIOTIC RESISTANCE GENES WITH LIMITED SEMI-QUANTITATIVE RESULTS
0202U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC NUCLEIC ACID (DNA OR RNA), 22 TARGETS INCLUDING SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2), QUALITATIVE RT-PCR, NASOPHARYNGEAL SWAB, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED
0223U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC NUCLEIC ACID (DNA OR RNA), 22 TARGETS INCLUDING SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2), QUALITATIVE RT-PCR, NASOPHARYNGEAL SWAB, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED
0225U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION) PATHOGEN-SPECIFIC DNA AND RNA, 21 TARGETS, INCLUDING SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2), AMPLIFIED PROBE TECHNIQUE, INCLUDING MULTIPLEX REVERSE TRANSCRIPTION FOR RNA TARGETS, EACH ANALYTE REPORTED AS DETECTED OR NOT DETECTED

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

(87 Codes)
Group 1 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 1: Codes. One of these diagnosis codes must be on the claim in addition to the sign or symptom for which there is suspicion of respiratory illness.

Group 1 Codes
CodeDescription
B97.29 Other coronavirus as the cause of diseases classified elsewhere
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
D80.7 Transient hypogammaglobulinemia of infancy
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
D81.819 Biotin-dependent carboxylase deficiency, unspecified
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
D82.9 Immunodeficiency associated with major defect, unspecified
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
J06.9 Acute upper respiratory infection, unspecified
J09.X1 Influenza due to identified novel influenza A virus with pneumonia
J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations
J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations
J09.X9 Influenza due to identified novel influenza A virus with other manifestations
J12.0 Adenoviral pneumonia
J12.1 Respiratory syncytial virus pneumonia
J12.3 Human metapneumovirus pneumonia
J12.81 Pneumonia due to SARS-associated coronavirus
J12.82 Pneumonia due to coronavirus disease 2019
J12.89 Other viral pneumonia
J12.9 Viral pneumonia, unspecified
J16.8 Pneumonia due to other specified infectious organisms
J18.0 Bronchopneumonia, unspecified organism
J18.1 Lobar pneumonia, unspecified organism
J18.2 Hypostatic pneumonia, unspecified organism
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
J20.8 Acute bronchitis due to other specified organisms
J22 Unspecified acute lower respiratory infection
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.8 Other specified cough
R06.2 Wheezing
R50.9 Fever, unspecified
T80.82XS Complication of immune effector cellular therapy, sequela
Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out
Z20.822 Contact with and (suspected) exposure to COVID-19
Z20.828 Contact with and (suspected) exposure to other viral communicable diseases
Z86.16 Personal history of COVID-19
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
U07.1 COVID-19

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

Group 1

Group 1 Paragraph

N/A

Group 1 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.

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.

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 R16

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.

02/03/2022 R15

Under CPT/HCPCS Codes Group 1: Paragraph deleted the sentence, "May only be billed in places of service 20, 21, 23, or 81 (Urgent care, Inpatient hospital, Emergency room, or Independent Laboratory respectively)" and added new paragraph that reads, "During the Federally designated public health emergency (PHE), the following place of service (POS) codes may be billed: 05, 06, 07, 08, 11, 17, 19, 20, 21, 22, 23, 24, 26, 49, 50, 71, 72, 81." The sentence, "The following paragraph does not apply during the PHE:" was added before the last paragraph. Under Group 1 ICD-10 Codes: Added J09.X1, J09.X2, J09.X3, J09.X9, J12.0, J12.1, J12.3

This revision is retroactive effective for dates of service on or after 02/03/2021.

04.01.2021: Typographical Error: Under ICD-10 Codes that Support Medical Necessity Group 1: Code R05 was deleted effective 04.01.2021.

Typographical Error: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted R05 and J15.8 effective 04.01.2021

10/01/2021 R14

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted R05 and added R05.1, R05.2, R05.3, R05.8, T80.82XS, Z92.850, Z92.858, Z92.86. This revision is due to the Annual ICD-10 Code Update and is effective on 10/1/2021.

04/01/2021 R13

Under CPT/HCPCS Codes Group 2: Codes 0098U, 0099U, 0100U were deleted and the code description was revised for 0202U and 0225U. This revision is due to the Q2 2021 CPT/HCPCS Code Update and is effective for dates of service on or after 4/1/2021.

01/01/2021 R12

Under Article Text revised the first bullet to read, “If the panel being used does not have its own proprietary CPT® code, select the appropriate CPT® code”. Under CPT/HCPCS Codes Group 1: Codes added 87636, 87637, 0240U, and 0241U. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 10/6/2020.

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added J12.82, Z20.822, and Z86.16. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

01/01/2021 R11

Under CPT/HCPCS Codes Group 1: Codes added 87636, 87637, 0240U and 0241U. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is effective for dates of service on or after 01/01/2021.

10/01/2020 R10

10/01/2020: Under CPT/HCPCS Codes Group 2: Codes added 0225U. This revision is due to the Q4 2020 CPT/HCPCS Code Update and is effective for dates of service on or after 08/10/2020.

10/01/2020 R9

Under CPT/HCPCS Codes Group 1: Paragraph added verbiage regarding place of service "81" and "Independent Laboratory" to the first paragraph. Under CPT/HCPCS Codes Group 1 Codes deleted U0003 and U0004.

07/30/2020 R8

Under CPT/HCPCS Codes Group 1: Codes added U0003 and U0004. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph removed the verbiage “87631” and replaced it with “CPT/HCPCS Codes Group 1: Codes.” This revision is due to the Q3 2020 CPT/HCPCS Code Update and is effective for dates of service on or after 7/1/2020.

Under CPT/HCPCS Codes Group 2: Codes added 0151U. This revision is retroactive effective for dates of service on or after 7/30/20.

07/30/2020 R7

Under Article Text removed the verbiage from the second bullet point and added the verbiage “If the test does have a PLA code then submit the appropriate code”. Removed the verbiage from the third bullet point and added the verbiage “Per the MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels LCD, tests that include more than 5 viral pathogens are non-covered. Included in this are 87632, 87633, and additional PLA codes listed in the CPT/HCPCS Codes Group 2: Codes section of this Billing and Coding article”. Under CPT/HCPCS Codes Group 1: Paragraph added the word “only” and removed the verbiage “by a provider of any medical specialty for whom the ordering of this test is within the provider’s scope of practice and institutional privileges” from the second sentence.

Under CPT/HCPCS Codes Group 1: Paragraph added the word “only” and removed the verbiage “by a provider of any medical specialty for whom the ordering of this test is within the provider’s scope of practice and institutional privileges” from the second sentence.

04/01/2020 R6

Under Article Guidance in second bullet: Added verbiage: Per the LCD this code is non-covered after BioFire® Diagnostics should report 0100U. Added 0115U, 0202U and 0223U to Paragraph: While each of these panels are able to report results for a specific number of pathogens, this contractor will interpret the use of 0098U, 0099U, and 100U, 0115U, 0202U and 0223U to represent the use of a specific testing platform regardless of the number of pathogens reported by the laboratory.

Removed from ICD-10 Codes that Support Medical Necessity Group I Paragraph - ICD-10 Codes that Support Medical Necessity: 0098U, 0099U, 0100U and 0115U.

Group I CPT/HCPCS Codes: Moved 0098U; 0099U; 0100U to Group II Codes - Noncovered, effective for dates of service on or after 7/1/2019.

Group I CPT/HCPCS Codes: Moved 0115U to Group II Codes - Noncovered, effective for dates of service on or after 10/1/2019.

Group II CPT/HCPCS Codes: Added 0202U and 0223U - Codes added per Quarterly CPT/HCPCS Code Update effective on or after 07/01/2020.

Due to MCD limitations, a revision effective date may not be retroactive. Corresponding effective dates are specified within this revision history.

04/01/2020 R5

Under ICD-10 Codes that Support Medical Necessity Group I Codes: U07.1 added. This revision is due to the Q2 2020 Code Update and is effective for dates of service on or after 04/01/2020.

02/20/2020 R4

02/20/2020: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added B97.29; J12.81; J12.89; J12.9; J15.8; J16.8; J18.0; J18.1; J18.2;J18.8; J18.9; J20.8; R05; R06.2; Z03.818; Z20.828. This revision is retroactive effective for dates of service on or after 2/20/20.

01/01/2020 R3

01/01/2020: Under CPT/HCPCS Codes Group 1: Codes the description changed for 0100U. This revision is due to the Q1 2020 CPT/HCPCS Code Update and is effective for dates of service on or after 1/1/2020.

11/02/2019 R2

Under ICD-10 Codes that Support Medical Necessity Group I Codes: added ICD-10 codes J22 and J06.9 to Group I codes. This is due to an article revision request per MolDX contractor.

10/01/2019 R1

10/01/2019: Under Article Text added the third bullet point verbiage "For dates of service on or after 10/1/2019, laboratories billing for services using GenMark®" ePlex Respiratory Pathogen (RP) Panel should report 0115U. While this panel is able to report results for a specific number of pathogens, this contractor will interpret the use of 0115U to represent the use of a specific testing platform regardless of the number of pathogens reported by the laboratory". Under CPT/HCPCS Codes Group 1: Codes added 0115U. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph added the verbiage "and 0115U".

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Public Versions
Updated On Effective Dates Status
06/01/2022 02/03/2022 - 06/01/2022 Retired You are here
01/24/2022 02/03/2022 - N/A Superseded View
09/02/2021 10/01/2021 - 02/02/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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