SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Respiratory Pathogen Panel Testing

A58741

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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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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A58741
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Respiratory Pathogen Panel Testing
Article Type
Billing and Coding
Original Effective Date
12/01/2021
Revision Effective Date
04/01/2022
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 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

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 15, Section 80.1 Clinical Laboratory Services
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 16 Laboratory Services
    • Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure Codes, Section 20.9 National Correct Coding Initiative (NCCI), Section 40 Clinical Diagnostic Laboratory Fee Schedule
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 3, Section 3.4.1.3 Diagnosis Code Requirements

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.

National Correct Coding Initiative:

  • NCCI Policy Manual for Medicare Services
    • Chapter 10, Pathology and Laboratory Services (CPT Codes 80000-89999), Section K Microbiology

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39027, Respiratory Pathogen Panel Testing. 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 respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A respiratory pathogen panel test must not be unbundled and billed as individual components regardless of the fact that the panel reports multiple individual pathogens and/or targets.

The term "panel" refers to all respiratory pathogens tested in the outpatient setting on a single date of service from a single biologic specimen, not ordered as a reflex test.

Please note: The services addressed in this article and related LCD are not applicable to providers submitting claims on institutional claim forms.

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.
  4. The medical record MUST support that the test was completed in a Part B setting that is equipped to deliver timely results AND for patients where the test demonstrates that clinical management can result in an improved health outcome.

Response To Comments

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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(192 Codes)
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 codes support medical necessity and provide coverage for CPT codes: 87428, 87631, 87636, 87637, 0240U, 0241U when used in the outpatient setting as outlined in the related LCD.

Group 1 Codes
Code Description
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
D80.8 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
D81.32 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
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
D89.0 Polyclonal hypergammaglobulinemia
D89.1 Cryoglobulinemia
D89.2 Hypergammaglobulinemia, unspecified
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
E84.0 Cystic fibrosis with pulmonary manifestations
E84.19 Cystic fibrosis with other intestinal manifestations
E84.8 Cystic fibrosis with other manifestations
I27.0 Primary pulmonary hypertension
I27.21 Secondary pulmonary arterial hypertension
I27.22 Pulmonary hypertension due to left heart disease
I27.23 Pulmonary hypertension due to lung diseases and hypoxia
I27.24 Chronic thromboembolic pulmonary hypertension
I27.29 Other secondary pulmonary hypertension
I27.81 Cor pulmonale (chronic)
I27.82 Chronic pulmonary embolism
I27.83 Eisenmenger's syndrome
I27.89 Other specified pulmonary heart diseases
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.811 Acute right heart failure
I50.812 Chronic right heart failure
I50.813 Acute on chronic right heart failure
I50.814 Right heart failure due to left heart failure
I50.82 Biventricular heart failure
I50.83 High output heart failure
I50.84 End stage heart failure
I50.89 Other heart failure
J00 Acute nasopharyngitis [common cold]
J02.9 Acute pharyngitis, unspecified
J04.0 Acute laryngitis
J04.10 Acute tracheitis without obstruction
J04.11 Acute tracheitis with obstruction
J04.2 Acute laryngotracheitis
J04.30 Supraglottitis, unspecified, without obstruction
J04.31 Supraglottitis, unspecified, with obstruction
J05.0 Acute obstructive laryngitis [croup]
J05.10 Acute epiglottitis without obstruction
J05.11 Acute epiglottitis with obstruction
J06.0 Acute laryngopharyngitis
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
J12.3 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
J15.8 Pneumonia due to other specified bacteria
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
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J60 Coalworker's pneumoconiosis
J61 Pneumoconiosis due to asbestos and other mineral fibers
J62.0 Pneumoconiosis due to talc dust
J62.8 Pneumoconiosis due to other dust containing silica
J63.0 Aluminosis (of lung)
J63.1 Bauxite fibrosis (of lung)
J63.2 Berylliosis
J63.3 Graphite fibrosis (of lung)
J63.4 Siderosis
J63.5 Stannosis
J63.6 Pneumoconiosis due to other specified inorganic dusts
J65 Pneumoconiosis associated with tuberculosis
J66.0 Byssinosis
J66.1 Flax-dressers' disease
J66.2 Cannabinosis
J66.8 Airway disease due to other specific organic dusts
J70.1 Chronic and other pulmonary manifestations due to radiation
J70.3 Chronic drug-induced interstitial lung disorders
J81.1 Chronic pulmonary edema
J84.10 Pulmonary fibrosis, unspecified
J84.111 Idiopathic interstitial pneumonia, not otherwise specified
J84.112 Idiopathic pulmonary fibrosis
J84.113 Idiopathic non-specific interstitial pneumonitis
J84.114 Acute interstitial pneumonitis
J84.115 Respiratory bronchiolitis interstitial lung disease
J84.116 Cryptogenic organizing pneumonia
J84.117 Desquamative interstitial pneumonia
J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere
J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.2 Lymphoid interstitial pneumonia
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.89 Other specified interstitial pulmonary diseases
J84.9 Interstitial pulmonary disease, unspecified
R04.2 Hemoptysis
R05.1 Acute cough
R05.2 Subacute cough
R06.02 Shortness of breath
R06.03 Acute respiratory distress
R06.1 Stridor
R06.2 Wheezing
R06.82 Tachypnea, not elsewhere classified
R07.1 Chest pain on breathing
R07.81 Pleurodynia
R09.02 Hypoxemia
R09.1 Pleurisy
R43.0 Anosmia
R43.9 Unspecified disturbances of smell and taste
R50.81 Fever presenting with conditions classified elsewhere
R50.9 Fever, unspecified
R53.1 Weakness
R55 Syncope and collapse
R68.83 Chills (without fever)
R79.81 Abnormal blood-gas level
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
U07.1 COVID-19
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*J12.82 must be reported with U07.1

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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 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

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Group 1 Paragraph

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Group 1 Codes

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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

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Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
04/01/2022 R2

Due to the Quarterly updates, 0151U has been deleted from Group 2: Codes in the CPT/HCPCS Codes section.

01/01/2022 R1

Due to the annual CPT/HCPCS code updates the long code description for 87428 has been changed.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L39027 - Respiratory Pathogen Panel Testing
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/20/2023 04/01/2022 - N/A Currently in Effect View
04/10/2022 04/01/2022 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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