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LCD Reference Article Billing and Coding Article

Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A58747

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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
A58747
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
Article Type
Billing and Coding
Original Effective Date
04/17/2022
Revision Effective Date
07/01/2025
Revision Ending Date
N/A
Retirement Date
N/A

CPT codes, descriptions, and other data only are copyright 2024 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

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, §80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing L39038.

To report a service for Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing, please submit the following claim information:

  • Select the appropriate CPT® or PLA code
    • If the panel being used does not have its own proprietary CPT® or PLA code, select the appropriate CPT® code and follow the additional instructions for the given 'panel' in the relevant Group paragraphs below. If no specific CPT® code exists for the test submitted, bill with CPT® code 87999.
  • CPT® codes that are not billed with the appropriate accompanying ICD-10 codes listed in this Billing and Coding Article will be denied. Tests with other indicated uses may therefore submit for a Z-code and undergo a Technical Assessment (TA) by MolDX. Tests using CPT® code 87999 will also require a Z-Code and a TA.
  • Tests that are FDA-approved/cleared and performed in ways consistent with their intended use labeling directions do not require a Z-code when billed with an appropriate accompanying ICD-10 code. However, the performance of multiple (>1) FDA-approved/cleared molecular Infectious Disease pathogen identification tests on the same date of service (DOS) for the same intended use on the same patient sample is considered as one distinct service and requires a Z-Code and a TA. If an existing CPT® code does not identify the service, it requires the use of CPT® code 87999.
  • Add modifier 59 for different species or strains reported by the same code, as allowed by the policy.
  • Enter 1 unit of service (UOS)
  • If applicable, 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
    • Box 19 for paper claim
  • If applicable, 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
  • Select the appropriate ICD-10-CM code(s)

NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.

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.

Additional information:

  • Panels intended for home use (including those that have been FDA approved or cleared) do NOT meet the coverage criteria of the policy.
  • This contractor expects that critically ill patients will be tested and managed in the appropriate critical care facility.
  • The test panel is a single test with multiple components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed as individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. If additional organisms are not included in a panel, testing for those organisms separately may be reasonable and necessary when ordered in addition to the panel and supported by documentation in the medical record.
  • As outlined in the policy, for a given date of service for the same clinical indication, the performance of an additional panel for content that is non-duplicative can only be billed for the non-duplicative content if supported by documentation in the medical record and all other criteria outlined in the associated policy.
    • When 2 or more codes within a given Group OR from 2 related Groups (i.e., Groups 1 and 6 which pertain to Respiratory panels, or Groups 2 and 7 which pertain to Gastrointestinal panels) are submitted for the same beneficiary on the same date of service for the same (or highly similar) intended use, the claims processing system will reject every code submitted after the first service. As outlined in the policy, exceptions may be allowed in limited circumstances for bloodstream and meningoencephalitis panels testing for non-duplicative content. For such cases, if a lab runs more than 1 distinct procedural service from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service.
  • Repeat panel tests for the same clinical indication will NOT be reimbursed, except according to the criteria outlined in the related LCD (i.e., 1 additional panel test may be performed between 1 and 14 days after the initial panel test, so long as the test fulfills the criteria for coverage as set forth in the policy).
  • Laboratories that are billing for multiple individual pathogens using the 59 modifier rather than panels may be subject to medical review as outliers. Similarly, laboratories billing for multiple related panels may be subject to medical review as outliers.
  • It is understood that in certain instances in which only targeted testing is appropriate, institutions may not have access to small panels and may have to perform larger panels for technical reasons. In such cases, Palmetto will pay only for components of a service that are reasonable and necessary.
  • For Expanded (>5 pathogens) RP, PNP, and GI Panels the following additional conditions apply:
    1. Testing is billed according to 1 of the following:

(a) Places of service (POS) 19, 21, 22, 23, OR

(b) The test is ordered as follows (for healthcare POS other than the POS listed in 1(a)):

(1) For immune-competent beneficiaries, the test must be ordered by an Infectious Disease Specialist or 1 of the following: Pulmonologist (for the RP and PNP panels) or Gastroenterologist (for the GI panels) who is diagnosing and treating the beneficiary.

(2) For immune-compromised beneficiaries, the test must be ordered by a clinician specialist in 1 of the following: Infectious Diseases, Oncology, Transplant (for any panel),Pulmonologist (for the RP and PNP panels), or Gastroenterologist (for the GI panels) who is diagnosing and treating the beneficiary.

(3) Regarding (1) and (2), An exception may be made in geographic locations where the specialist(s) cannot be reasonably reached by the beneficiary, and the ordering provider is located closer to the beneficiary’s place of residence than the nearest 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.

(4) An ICD-10 diagnosis code from Group 6 or Group 7 must be on the claim, in addition to the sign or symptom (from Groups 1 or 2) for which there is suspicion of respiratory or gastrointestinal illness in order to bill for the RP/PNP or GI panels, respectively. See the specific instructions in Groups 6 and 7 below. The exception to this is testing that is performed as part of a pre-transplant evaluation of an immune-compromised beneficiary, regardless of the presence of symptoms. In such cases, clear documentation of the pre-transplant evaluation must accompany the claim.

The expanded/targeted panel distinction is not applicable to all panels, except as otherwise indicated in the related policy.

Response To Comments

Number Comment Response
1
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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

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Group 1

(1 Code)
Group 1 Paragraph

N/A

 Group 1 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 2

(1 Code)
Group 2 Paragraph

N/A

 Group 2 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 3

(1 Code)
Group 3 Paragraph

N/A

 Group 3 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 4

(1 Code)
Group 4 Paragraph

N/A

 Group 4 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 5

(1 Code)
Group 5 Paragraph

N/A

 Group 5 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 6

(1 Code)
Group 6 Paragraph

N/A

 Group 6 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 7

(1 Code)
Group 7 Paragraph

N/A

 Group 7 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 8

(1 Code)
Group 8 Paragraph

N/A

 Group 8 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 9

(1 Code)
Group 9 Paragraph

N/A

 Group 9 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 10

(1 Code)
Group 10 Paragraph

N/A

 Group 10 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 11

(1 Code)
Group 11 Paragraph

N/A

 Group 11 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.

Group 12

(1 Code)
Group 12 Paragraph

N/A

 Group 12 Codes
Code Description
59 DISTINCT PROCEDURAL SERVICE: UNDER CERTAIN CIRCUMSTANCES, THE PHYSICIAN MAY NEED TO INDICATE THAT A PROCEDURE OR SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES PERFORMED ON THE SAME DAY. MODIFIER -59 IS USED TO IDENTIFY PROCEDURES/SERVICES THAT ARE NOT NORMALLY REPORTED TOGETHER, BUT ARE APPROPRIATE UNDER THE CIRCUMSTANCES. THIS MAY REPRESENT A DIFFERENT SESSION OR PATIENT ENCOUNTER, DIFFERENT PROCEDURE OR SURGERY, DIFFERNET SITE OR ORGAN SYSTEM, SEPARATE INCISION/EXCISION, SEPARATE LESION, OR SEPARATE INJURY (OR AREA OF INJURY IN EXTENSIVE INJURIES) NOT ORDINARILY ENCOUNTERED OR PERFORMED ON THE SAME DAY BY THE SAME PHYSICIAN. HOWEVER, WHAN ANOTHER ALREADY ESTABLISHED MODIFIER IS APPROPRIATE IT SHOULD BE USED RATHER THAN MODIFIER -59. ONLY IF NO MORE DESCRIPTIVE MODIFIER IS AVAILABLE, AND THE USE OF MODIFIER -59 BEST EXPLAINS THE CIRCUMSTANCES, SHOULD MODIFIER -59 BE USED. MODIFIER CODE 09959 MAY BE USED AS AN ALTERNATE TO MODIFIER -59.
N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

(112 Codes)
Group 1 Paragraph

One of the following diagnosis codes must be on the claim to bill for:

Targeted Respiratory Panels

 Group 1 Codes
Code Description
A37.00 Whooping cough due to Bordetella pertussis without pneumonia
A37.01 Whooping cough due to Bordetella pertussis with pneumonia
A37.10 Whooping cough due to Bordetella parapertussis without pneumonia
A37.11 Whooping cough due to Bordetella parapertussis with pneumonia
A37.80 Whooping cough due to other Bordetella species without pneumonia
A37.81 Whooping cough due to other Bordetella species with pneumonia
A37.90 Whooping cough, unspecified species without pneumonia
A37.91 Whooping cough, unspecified species with pneumonia
A41.81 Sepsis due to Enterococcus
A41.89 Other specified sepsis
A41.9 Sepsis, unspecified organism
A48.1 Legionnaires' disease
A48.2 Nonpneumonic Legionnaires' disease [Pontiac fever]
B25.0 Cytomegaloviral pneumonitis
B33.23 Viral pericarditis
B33.24 Viral cardiomyopathy
B59 Pneumocystosis
B97.21 SARS-associated coronavirus as the cause of diseases classified elsewhere
B97.29 Other coronavirus as the cause of diseases classified elsewhere
J05.0 Acute obstructive laryngitis [croup]
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
J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia
J10.08 Influenza due to other identified influenza virus with other specified pneumonia
J10.1 Influenza due to other identified influenza virus with other respiratory manifestations
J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations
J10.81 Influenza due to other identified influenza virus with encephalopathy
J10.82 Influenza due to other identified influenza virus with myocarditis
J10.83 Influenza due to other identified influenza virus with otitis media
J10.89 Influenza due to other identified influenza virus with other manifestations
J11.08 Influenza due to unidentified influenza virus with specified pneumonia
J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations
J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations
J11.81 Influenza due to unidentified influenza virus with encephalopathy
J11.82 Influenza due to unidentified influenza virus with myocarditis
J11.83 Influenza due to unidentified influenza virus with otitis media
J11.89 Influenza due to unidentified influenza virus with other manifestations
J12.0 Adenoviral pneumonia
J12.1 Respiratory syncytial virus pneumonia
J12.2 Parainfluenza 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
J13 Pneumonia due to Streptococcus pneumoniae
J15.0 Pneumonia due to Klebsiella pneumoniae
J15.1 Pneumonia due to Pseudomonas
J15.20 Pneumonia due to staphylococcus, unspecified
J15.211 Pneumonia due to Methicillin susceptible Staphylococcus aureus
J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
J15.29 Pneumonia due to other staphylococcus
J15.3 Pneumonia due to streptococcus, group B
J15.4 Pneumonia due to other streptococci
J15.61 Pneumonia due to Acinetobacter baumannii
J15.69 Pneumonia due to other Gram-negative bacteria
J15.7 Pneumonia due to Mycoplasma pneumoniae
J15.8 Pneumonia due to other specified bacteria
J15.9 Unspecified bacterial pneumonia
J16.0 Chlamydial pneumonia
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
J20.0 Acute bronchitis due to Mycoplasma pneumoniae
J20.1 Acute bronchitis due to Hemophilus influenzae
J20.2 Acute bronchitis due to streptococcus
J20.3 Acute bronchitis due to coxsackievirus
J20.4 Acute bronchitis due to parainfluenza virus
J20.5 Acute bronchitis due to respiratory syncytial virus
J20.6 Acute bronchitis due to rhinovirus
J20.8 Acute bronchitis due to other specified organisms
J20.9 Acute bronchitis, unspecified
J21.9 Acute bronchiolitis, unspecified
J22 Unspecified acute lower respiratory infection
J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J84.116 Cryptogenic organizing pneumonia
J84.117 Desquamative interstitial pneumonia
J84.2 Lymphoid interstitial pneumonia
J85.0 Gangrene and necrosis of lung
J85.1 Abscess of lung with pneumonia
J85.2 Abscess of lung without pneumonia
J85.3 Abscess of mediastinum
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.8 Other specified cough
R06.02 Shortness of breath
R06.03 Acute respiratory distress
R06.2 Wheezing
R50.9 Fever, unspecified
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
R78.81 Bacteremia
T86.33 Heart-lung transplant infection
T86.812 Lung transplant infection
Z03.818 Encounter for observation for suspected exposure to other biological agents ruled out
U07.1 COVID-19

Group 2

(115 Codes)
Group 2 Paragraph

One of the following diagnosis codes must be on the claim to bill for:

Targeted Gastrointestinal Panels

 Group 2 Codes
Code Description
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
A02.1 Salmonella sepsis
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
A08.19 Acute gastroenteropathy due to other small round viruses
A08.2 Adenoviral enteritis
A08.31 Calicivirus enteritis
A08.32 Astrovirus enteritis
A08.39 Other viral enteritis
A08.8 Other specified intestinal infections
A09 Infectious gastroenteritis and colitis, unspecified
A32.11 Listerial meningitis
A32.12 Listerial meningoencephalitis
A32.7 Listerial sepsis
A41.50 Gram-negative sepsis, unspecified
A41.51 Sepsis due to Escherichia coli [E. coli]
A41.52 Sepsis due to Pseudomonas
A41.53 Sepsis due to Serratia
A41.59 Other Gram-negative sepsis
A41.81 Sepsis due to Enterococcus
A41.89 Other specified sepsis
A41.9 Sepsis, unspecified organism
D59.30 Hemolytic-uremic syndrome, unspecified
D59.31 Infection-associated hemolytic-uremic syndrome
K35.200 Acute appendicitis with generalized peritonitis, without perforation or abscess
K35.201 Acute appendicitis with generalized peritonitis, with perforation, without abscess
K35.209 Acute appendicitis with generalized peritonitis, without abscess, unspecified as to perforation
K35.210 Acute appendicitis with generalized peritonitis, without perforation, with abscess
K35.211 Acute appendicitis with generalized peritonitis, with perforation and abscess
K35.219 Acute appendicitis with generalized peritonitis, with abscess, unspecified as to perforation
K50.014 Crohn's disease of small intestine with abscess
K50.114 Crohn's disease of large intestine with abscess
K50.814 Crohn's disease of both small and large intestine with abscess
K50.914 Crohn's disease, unspecified, with abscess
K51.014 Ulcerative (chronic) pancolitis with abscess
K51.214 Ulcerative (chronic) proctitis with abscess
K51.314 Ulcerative (chronic) rectosigmoiditis with abscess
K51.414 Inflammatory polyps of colon with abscess
K51.514 Left sided colitis with abscess
K51.814 Other ulcerative colitis with abscess
K51.914 Ulcerative colitis, unspecified with abscess
K52.1 Toxic gastroenteritis and colitis
K56.0 Paralytic ileus
K63.8211 Small intestinal bacterial overgrowth, hydrogen-subtype
K63.8212 Small intestinal bacterial overgrowth, hydrogen sulfide-subtype
K63.8219 Small intestinal bacterial overgrowth, unspecified
K63.822 Small intestinal fungal overgrowth
K63.829 Intestinal methanogen overgrowth, unspecified
K92.1 Melena
M31.19 Other thrombotic microangiopathy
R10.0 Acute abdomen
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.811 Right upper quadrant abdominal tenderness
R10.812 Left upper quadrant abdominal tenderness
R10.813 Right lower quadrant abdominal tenderness
R10.814 Left lower quadrant abdominal tenderness
R10.815 Periumbilic abdominal tenderness
R10.817 Generalized abdominal tenderness
R10.821 Right upper quadrant rebound abdominal tenderness
R10.822 Left upper quadrant rebound abdominal tenderness
R10.823 Right lower quadrant rebound abdominal tenderness
R10.824 Left lower quadrant rebound abdominal tenderness
R10.825 Periumbilic rebound abdominal tenderness
R10.826 Epigastric rebound abdominal tenderness
R10.827 Generalized rebound abdominal tenderness
R10.829 Rebound abdominal tenderness, unspecified site
R10.84 Generalized abdominal pain
R19.5 Other fecal abnormalities
R19.7 Diarrhea, unspecified
R50.9 Fever, unspecified
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
R78.81 Bacteremia
T86.852 Intestine transplant infection

Group 3

(56 Codes)
Group 3 Paragraph

One of the following diagnosis codes must be on the claim to bill for:

Meningoencephalitis Panels

 Group 3 Codes
Code Description
A39.0 Meningococcal meningitis
A39.81 Meningococcal encephalitis
A39.9 Meningococcal infection, unspecified
A41.9 Sepsis, unspecified organism
A54.81 Gonococcal meningitis
A80.0 Acute paralytic poliomyelitis, vaccine-associated
A80.1 Acute paralytic poliomyelitis, wild virus, imported
A80.2 Acute paralytic poliomyelitis, wild virus, indigenous
A80.30 Acute paralytic poliomyelitis, unspecified
A80.39 Other acute paralytic poliomyelitis
A80.4 Acute nonparalytic poliomyelitis
A80.9 Acute poliomyelitis, unspecified
A85.0 Enteroviral encephalitis
A85.1 Adenoviral encephalitis
A85.8 Other specified viral encephalitis
A86 Unspecified viral encephalitis
A87.0 Enteroviral meningitis
A87.8 Other viral meningitis
A87.9 Viral meningitis, unspecified
B00.3 Herpesviral meningitis
B00.4 Herpesviral encephalitis
B01.0 Varicella meningitis
B01.11 Varicella encephalitis and encephalomyelitis
B02.1 Zoster meningitis
B10.01 Human herpesvirus 6 encephalitis
B20 Human immunodeficiency virus [HIV] disease
B27.02 Gammaherpesviral mononucleosis with meningitis
B27.12 Cytomegaloviral mononucleosis with meningitis
B27.82 Other infectious mononucleosis with meningitis
B37.5 Candidal meningitis
B45.1 Cerebral cryptococcosis
B60.2 Naegleriasis
G00.0 Hemophilus meningitis
G00.1 Pneumococcal meningitis
G00.2 Streptococcal meningitis
G00.8 Other bacterial meningitis
G00.9 Bacterial meningitis, unspecified
G03.0 Nonpyogenic meningitis
G03.9 Meningitis, unspecified
G04.01 Postinfectious acute disseminated encephalitis and encephalomyelitis (postinfectious ADEM)
G04.02 Postimmunization acute disseminated encephalitis, myelitis and encephalomyelitis
G04.30 Acute necrotizing hemorrhagic encephalopathy, unspecified
G04.31 Postinfectious acute necrotizing hemorrhagic encephalopathy
G04.32 Postimmunization acute necrotizing hemorrhagic encephalopathy
G04.39 Other acute necrotizing hemorrhagic encephalopathy
G04.81 Other encephalitis and encephalomyelitis
G04.82 Acute flaccid myelitis
G04.89 Other myelitis
G04.90 Encephalitis and encephalomyelitis, unspecified
G04.91 Myelitis, unspecified
G05.3 Encephalitis and encephalomyelitis in diseases classified elsewhere
G05.4 Myelitis in diseases classified elsewhere
R41.82 Altered mental status, unspecified
R50.9 Fever, unspecified
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock

Group 4

(78 Codes)
Group 4 Paragraph

One of the following diagnosis codes must be on the claim to bill for:

Bloodstream Infection Panels

 Group 4 Codes
Code Description
A01.00 Typhoid fever, unspecified
A01.01 Typhoid meningitis
A01.02 Typhoid fever with heart involvement
A01.03 Typhoid pneumonia
A01.04 Typhoid arthritis
A01.05 Typhoid osteomyelitis
A01.09 Typhoid fever with other complications
A01.1 Paratyphoid fever A
A01.2 Paratyphoid fever B
A01.3 Paratyphoid fever C
A32.7 Listerial sepsis
A40.0 Sepsis due to streptococcus, group A
A40.1 Sepsis due to streptococcus, group B
A40.3 Sepsis due to Streptococcus pneumoniae
A40.8 Other streptococcal sepsis
A40.9 Streptococcal sepsis, unspecified
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
A41.1 Sepsis due to other specified staphylococcus
A41.2 Sepsis due to unspecified staphylococcus
A41.3 Sepsis due to Hemophilus influenzae
A41.4 Sepsis due to anaerobes
A41.50 Gram-negative sepsis, unspecified
A41.51 Sepsis due to Escherichia coli [E. coli]
A41.52 Sepsis due to Pseudomonas
A41.53 Sepsis due to Serratia
A41.54 Sepsis due to Acinetobacter baumannii
A41.59 Other Gram-negative sepsis
A41.9 Sepsis, unspecified organism
A54.86 Gonococcal sepsis
A79.82 Anaplasmosis [A. phagocytophilum]
B37.7 Candidal sepsis
B96.83 Acinetobacter baumannii as the cause of diseases classified elsewhere
B99.9 Unspecified infectious disease
D59.30 Hemolytic-uremic syndrome, unspecified
D59.31 Infection-associated hemolytic-uremic syndrome
D70.3 Neutropenia due to infection
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
I33.0 Acute and subacute infective endocarditis
M31.19 Other thrombotic microangiopathy
R50.81 Fever presenting with conditions classified elsewhere
R50.9 Fever, unspecified
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
R78.81 Bacteremia
T80.211A Bloodstream infection due to central venous catheter, initial encounter
T80.211D Bloodstream infection due to central venous catheter, subsequent encounter
T80.211S Bloodstream infection due to central venous catheter, sequela
T80.218A Other infection due to central venous catheter, initial encounter
T80.218D Other infection due to central venous catheter, subsequent encounter
T80.218S Other infection due to central venous catheter, sequela
T80.219A Unspecified infection due to central venous catheter, initial encounter
T80.219D Unspecified infection due to central venous catheter, subsequent encounter
T80.219S Unspecified infection due to central venous catheter, sequela
T80.22XA Acute infection following transfusion, infusion, or injection of blood and blood products, initial encounter
T80.22XD Acute infection following transfusion, infusion, or injection of blood and blood products, subsequent encounter
T80.22XS Acute infection following transfusion, infusion, or injection of blood and blood products, sequela
T80.29XA Infection following other infusion, transfusion and therapeutic injection, initial encounter
T80.29XD Infection following other infusion, transfusion and therapeutic injection, subsequent encounter
T80.29XS Infection following other infusion, transfusion and therapeutic injection, sequela
T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter
T82.6XXD Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter
T82.6XXS Infection and inflammatory reaction due to cardiac valve prosthesis, sequela
T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.7XXD Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter
T82.7XXS Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela
T85.71XA Infection and inflammatory reaction due to peritoneal dialysis catheter, initial encounter
T85.71XD Infection and inflammatory reaction due to peritoneal dialysis catheter, subsequent encounter
T85.71XS Infection and inflammatory reaction due to peritoneal dialysis catheter, sequela
T85.72XA Infection and inflammatory reaction due to insulin pump, initial encounter
T85.72XD Infection and inflammatory reaction due to insulin pump, subsequent encounter
T85.72XS Infection and inflammatory reaction due to insulin pump, sequela
T86.03 Bone marrow transplant infection
T86.23 Heart transplant infection
T86.33 Heart-lung transplant infection
T86.5 Complications of stem cell transplant

Group 5

(97 Codes)
Group 5 Paragraph

One of the following diagnosis codes must be on the claim to bill for:

Urogenital/Anogenital Panels

NOTE: Claims with diagnosis code Z11.3 would be expected to also include a high-risk diagnosis code.

 Group 5 Codes
Code Description
A51.0 Primary genital syphilis
A51.1 Primary anal syphilis
A51.31 Condyloma latum
A52.76 Other genitourinary symptomatic late syphilis
A54.00 Gonococcal infection of lower genitourinary tract, unspecified
A54.01 Gonococcal cystitis and urethritis, unspecified
A54.02 Gonococcal vulvovaginitis, unspecified
A54.03 Gonococcal cervicitis, unspecified
A54.09 Other gonococcal infection of lower genitourinary tract
A54.1 Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess
A54.21 Gonococcal infection of kidney and ureter
A54.22 Gonococcal prostatitis
A54.23 Gonococcal infection of other male genital organs
A54.24 Gonococcal female pelvic inflammatory disease
A54.29 Other gonococcal genitourinary infections
A54.6 Gonococcal infection of anus and rectum
A56.00 Chlamydial infection of lower genitourinary tract, unspecified
A56.01 Chlamydial cystitis and urethritis
A56.02 Chlamydial vulvovaginitis
A56.09 Other chlamydial infection of lower genitourinary tract
A56.11 Chlamydial female pelvic inflammatory disease
A56.19 Other chlamydial genitourinary infection
A56.2 Chlamydial infection of genitourinary tract, unspecified
A56.3 Chlamydial infection of anus and rectum
A59.00 Urogenital trichomoniasis, unspecified
A59.01 Trichomonal vulvovaginitis
A59.02 Trichomonal prostatitis
A59.03 Trichomonal cystitis and urethritis
A59.09 Other urogenital trichomoniasis
A60.00 Herpesviral infection of urogenital system, unspecified
A60.01 Herpesviral infection of penis
A60.02 Herpesviral infection of other male genital organs
A60.03 Herpesviral cervicitis
A60.04 Herpesviral vulvovaginitis
A60.09 Herpesviral infection of other urogenital tract
A60.1 Herpesviral infection of perianal skin and rectum
A60.9 Anogenital herpesviral infection, unspecified
A63.0 Anogenital (venereal) warts
B20 Human immunodeficiency virus [HIV] disease
B37.31 Acute candidiasis of vulva and vagina
B37.32 Chronic candidiasis of vulva and vagina
B37.41 Candidal cystitis and urethritis
B37.42 Candidal balanitis
B37.49 Other urogenital candidiasis
B37.89 Other sites of candidiasis
B97.35 Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere
D26.0 Other benign neoplasm of cervix uteri
L29.2 Pruritus vulvae
L29.3 Anogenital pruritus, unspecified
N34.1 Nonspecific urethritis
N34.2 Other urethritis
N41.0 Acute prostatitis
N41.3 Prostatocystitis
N48.5 Ulcer of penis
N76.0 Acute vaginitis
N76.1 Subacute and chronic vaginitis
N76.2 Acute vulvitis
N76.3 Subacute and chronic vulvitis
N76.5 Ulceration of vagina
N76.6 Ulceration of vulva
N76.82 Fournier disease of vagina and vulva
N76.89 Other specified inflammation of vagina and vulva
N77.1 Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere
N89.8 Other specified noninflammatory disorders of vagina
N90.89 Other specified noninflammatory disorders of vulva and perineum
N93.0 Postcoital and contact bleeding
N93.8 Other specified abnormal uterine and vaginal bleeding
O98.711 Human immunodeficiency virus [HIV] disease complicating pregnancy, first trimester
O98.712 Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester
O98.713 Human immunodeficiency virus [HIV] disease complicating pregnancy, third trimester
R10.2 Pelvic and perineal pain
R30.0 Dysuria
T74.21XA Adult sexual abuse, confirmed, initial encounter
T74.21XD Adult sexual abuse, confirmed, subsequent encounter
T74.21XS Adult sexual abuse, confirmed, sequela
T74.51XA Adult forced sexual exploitation, confirmed, initial encounter
T74.51XD Adult forced sexual exploitation, confirmed, subsequent encounter
T74.51XS Adult forced sexual exploitation, confirmed, sequela
T76.21XA Adult sexual abuse, suspected, initial encounter
T76.21XD Adult sexual abuse, suspected, subsequent encounter
T76.21XS Adult sexual abuse, suspected, sequela
T76.51XA Adult forced sexual exploitation, suspected, initial encounter
T76.51XD Adult forced sexual exploitation, suspected, subsequent encounter
T76.51XS Adult forced sexual exploitation, suspected, sequela
Z04.41 Encounter for examination and observation following alleged adult rape
Z04.71 Encounter for examination and observation following alleged adult physical abuse
Z04.81 Encounter for examination and observation of victim following forced sexual exploitation
Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission
Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission
Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Z33.1 Pregnant state, incidental
Z33.3 Pregnant state, gestational carrier
Z72.51 High risk heterosexual behavior
Z72.52 High risk homosexual behavior
Z72.53 High risk bisexual behavior
Z72.89 Other problems related to lifestyle

Group 6

(127 Codes)
Group 6 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 6: Codes - Expanded (>5 pathogens) Respiratory and Pneumonia Panels.

For testing in POS other than POS 19, 21, 22 or 23, to bill one of the Group 6 CPT codes, TWO ICD-10 codes are required- one from Group 6 and another from Group 1.

For immunocompromised patients, testing may be performed as part of a pre-transplant evaluation (once per transplant), regardless of the presence of symptoms. In such cases, clear documentation of the pre-transplant evaluation must accompany the claim.

 Group 6 Codes
Code Description
B20 Human immunodeficiency virus [HIV] disease
C46.0 Kaposi's sarcoma of skin
C46.1 Kaposi's sarcoma of soft tissue
C46.2 Kaposi's sarcoma of palate
C46.3 Kaposi's sarcoma of lymph nodes
C46.4 Kaposi's sarcoma of gastrointestinal sites
C46.50 Kaposi's sarcoma of unspecified lung
C46.51 Kaposi's sarcoma of right lung
C46.52 Kaposi's sarcoma of left lung
C46.7 Kaposi's sarcoma of other sites
D57.01 Hb-SS disease with acute chest syndrome
D61.03 Fanconi anemia
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
D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]
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
D84.9 Immunodeficiency, unspecified
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
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E84.0 Cystic fibrosis with pulmonary manifestations
J44.81 Bronchiolitis obliterans and bronchiolitis obliterans syndrome
J44.89 Other specified chronic obstructive pulmonary disease
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.991 Cough variant asthma
J70.1 Chronic and other pulmonary manifestations due to radiation
J84.01 Alveolar proteinosis
J84.02 Pulmonary alveolar microlithiasis
J84.03 Idiopathic pulmonary hemosiderosis
J84.10 Pulmonary fibrosis, unspecified
J84.112 Idiopathic pulmonary fibrosis
J84.114 Acute interstitial pneumonitis
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
J84.81 Lymphangioleiomyomatosis
J84.82 Adult pulmonary Langerhans cell histiocytosis
J84.89 Other specified interstitial pulmonary diseases
O98.711 Human immunodeficiency virus [HIV] disease complicating pregnancy, first trimester
O98.712 Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester
O98.713 Human immunodeficiency virus [HIV] disease complicating pregnancy, third trimester
T80.82XS Complication of immune effector cellular therapy, sequela
Z51.11 Encounter for antineoplastic chemotherapy
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
Z94.89 Other transplanted organ and tissue status

Group 7

(162 Codes)
Group 7 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 7: Codes - Expanded (>5 pathogens) Gastrointestinal Panels.

For testing in POS other than POS 19, 21, 22 or 23, to bill one of the Group 7 CPT codes, TWO ICD-10 codes are required- one from Group 7 and another from Group 2.

For immunocompromised patients, testing may be performed as part of a pre-transplant evaluation (once per transplant), regardless of the presence of symptoms. In such cases, clear documentation of the pre-transplant evaluation must accompany the claim.

 Group 7 Codes
Code Description
B20 Human immunodeficiency virus [HIV] disease
B25.1 Cytomegaloviral hepatitis
B25.2 Cytomegaloviral pancreatitis
C46.0 Kaposi's sarcoma of skin
C46.1 Kaposi's sarcoma of soft tissue
C46.2 Kaposi's sarcoma of palate
C46.3 Kaposi's sarcoma of lymph nodes
C46.4 Kaposi's sarcoma of gastrointestinal sites
C46.50 Kaposi's sarcoma of unspecified lung
C46.51 Kaposi's sarcoma of right lung
C46.52 Kaposi's sarcoma of left lung
C46.7 Kaposi's sarcoma of other sites
D61.03 Fanconi anemia
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
D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]
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
D84.9 Immunodeficiency, unspecified
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
E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
K50.011 Crohn's disease of small intestine with rectal bleeding
K50.012 Crohn's disease of small intestine with intestinal obstruction
K50.013 Crohn's disease of small intestine with fistula
K50.018 Crohn's disease of small intestine with other complication
K50.111 Crohn's disease of large intestine with rectal bleeding
K50.112 Crohn's disease of large intestine with intestinal obstruction
K50.113 Crohn's disease of large intestine with fistula
K50.118 Crohn's disease of large intestine with other complication
K50.812 Crohn's disease of both small and large intestine with intestinal obstruction
K50.813 Crohn's disease of both small and large intestine with fistula
K50.818 Crohn's disease of both small and large intestine with other complication
K50.911 Crohn's disease, unspecified, with rectal bleeding
K50.912 Crohn's disease, unspecified, with intestinal obstruction
K50.913 Crohn's disease, unspecified, with fistula
K50.918 Crohn's disease, unspecified, with other complication
K51.011 Ulcerative (chronic) pancolitis with rectal bleeding
K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction
K51.013 Ulcerative (chronic) pancolitis with fistula
K51.018 Ulcerative (chronic) pancolitis with other complication
K51.019 Ulcerative (chronic) pancolitis with unspecified complications
K51.211 Ulcerative (chronic) proctitis with rectal bleeding
K51.212 Ulcerative (chronic) proctitis with intestinal obstruction
K51.213 Ulcerative (chronic) proctitis with fistula
K51.218 Ulcerative (chronic) proctitis with other complication
K51.219 Ulcerative (chronic) proctitis with unspecified complications
K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding
K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction
K51.313 Ulcerative (chronic) rectosigmoiditis with fistula
K51.318 Ulcerative (chronic) rectosigmoiditis with other complication
K51.319 Ulcerative (chronic) rectosigmoiditis with unspecified complications
K51.411 Inflammatory polyps of colon with rectal bleeding
K51.412 Inflammatory polyps of colon with intestinal obstruction
K51.413 Inflammatory polyps of colon with fistula
K51.418 Inflammatory polyps of colon with other complication
K51.419 Inflammatory polyps of colon with unspecified complications
K51.511 Left sided colitis with rectal bleeding
K51.512 Left sided colitis with intestinal obstruction
K51.513 Left sided colitis with fistula
K51.518 Left sided colitis with other complication
K51.519 Left sided colitis with unspecified complications
K51.811 Other ulcerative colitis with rectal bleeding
K51.812 Other ulcerative colitis with intestinal obstruction
K51.813 Other ulcerative colitis with fistula
K51.818 Other ulcerative colitis with other complication
K51.911 Ulcerative colitis, unspecified with rectal bleeding
K51.912 Ulcerative colitis, unspecified with intestinal obstruction
K51.913 Ulcerative colitis, unspecified with fistula
K51.918 Ulcerative colitis, unspecified with other complication
K52.0 Gastroenteritis and colitis due to radiation
K56.3 Gallstone ileus
K62.7 Radiation proctitis
O98.711 Human immunodeficiency virus [HIV] disease complicating pregnancy, first trimester
O98.712 Human immunodeficiency virus [HIV] disease complicating pregnancy, second trimester
O98.713 Human immunodeficiency virus [HIV] disease complicating pregnancy, third trimester
T80.82XS Complication of immune effector cellular therapy, sequela
Z51.11 Encounter for antineoplastic chemotherapy
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
Z94.89 Other transplanted organ and tissue status

Group 8

Group 8 Paragraph

N/A

 Group 8 Codes

N/A

Group 9

(23 Codes)
Group 9 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 9: Codes - Zoonotic Infection Panels.

 Group 9 Codes
Code Description
A77.40 Ehrlichiosis, unspecified
A77.41 Ehrlichiosis chaffeensis [E. chaffeensis]
A77.49 Other ehrlichiosis
A79.82 Anaplasmosis [A. phagocytophilum]
A79.9 Rickettsiosis, unspecified
A84.89 Other tick-borne viral encephalitis
A84.9 Tick-borne viral encephalitis, unspecified
A85.2 Arthropod-borne viral encephalitis, unspecified
A85.8 Other specified viral encephalitis
A86 Unspecified viral encephalitis
A93.8 Other specified arthropod-borne viral fevers
A94 Unspecified arthropod-borne viral fever
B60.00 Babesiosis, unspecified
B60.01 Babesiosis due to Babesia microti
B60.02 Babesiosis due to Babesia duncani
B60.03 Babesiosis due to Babesia divergens
B60.09 Other babesiosis
G04.81 Other encephalitis and encephalomyelitis
G04.90 Encephalitis and encephalomyelitis, unspecified
R41.82 Altered mental status, unspecified
W57.XXXA Bitten or stung by nonvenomous insect and other nonvenomous arthropods, initial encounter
W57.XXXD Bitten or stung by nonvenomous insect and other nonvenomous arthropods, subsequent encounter
W57.XXXS Bitten or stung by nonvenomous insect and other nonvenomous arthropods, sequela

Group 10

(194 Codes)
Group 10 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 10: Codes - Joint Infection Panels. 

 Group 10 Codes
Code Description
A01.04 Typhoid arthritis
A02.23 Salmonella arthritis
A54.42 Gonococcal arthritis
M00.00 Staphylococcal arthritis, unspecified joint
M00.011 Staphylococcal arthritis, right shoulder
M00.012 Staphylococcal arthritis, left shoulder
M00.019 Staphylococcal arthritis, unspecified shoulder
M00.021 Staphylococcal arthritis, right elbow
M00.022 Staphylococcal arthritis, left elbow
M00.029 Staphylococcal arthritis, unspecified elbow
M00.031 Staphylococcal arthritis, right wrist
M00.032 Staphylococcal arthritis, left wrist
M00.039 Staphylococcal arthritis, unspecified wrist
M00.041 Staphylococcal arthritis, right hand
M00.042 Staphylococcal arthritis, left hand
M00.049 Staphylococcal arthritis, unspecified hand
M00.051 Staphylococcal arthritis, right hip
M00.052 Staphylococcal arthritis, left hip
M00.059 Staphylococcal arthritis, unspecified hip
M00.061 Staphylococcal arthritis, right knee
M00.062 Staphylococcal arthritis, left knee
M00.069 Staphylococcal arthritis, unspecified knee
M00.071 Staphylococcal arthritis, right ankle and foot
M00.072 Staphylococcal arthritis, left ankle and foot
M00.079 Staphylococcal arthritis, unspecified ankle and foot
M00.08 Staphylococcal arthritis, vertebrae
M00.09 Staphylococcal polyarthritis
M00.10 Pneumococcal arthritis, unspecified joint
M00.111 Pneumococcal arthritis, right shoulder
M00.112 Pneumococcal arthritis, left shoulder
M00.119 Pneumococcal arthritis, unspecified shoulder
M00.121 Pneumococcal arthritis, right elbow
M00.122 Pneumococcal arthritis, left elbow
M00.129 Pneumococcal arthritis, unspecified elbow
M00.131 Pneumococcal arthritis, right wrist
M00.132 Pneumococcal arthritis, left wrist
M00.139 Pneumococcal arthritis, unspecified wrist
M00.141 Pneumococcal arthritis, right hand
M00.142 Pneumococcal arthritis, left hand
M00.149 Pneumococcal arthritis, unspecified hand
M00.151 Pneumococcal arthritis, right hip
M00.152 Pneumococcal arthritis, left hip
M00.159 Pneumococcal arthritis, unspecified hip
M00.161 Pneumococcal arthritis, right knee
M00.162 Pneumococcal arthritis, left knee
M00.169 Pneumococcal arthritis, unspecified knee
M00.171 Pneumococcal arthritis, right ankle and foot
M00.172 Pneumococcal arthritis, left ankle and foot
M00.179 Pneumococcal arthritis, unspecified ankle and foot
M00.18 Pneumococcal arthritis, vertebrae
M00.211 Other streptococcal arthritis, right shoulder
M00.212 Other streptococcal arthritis, left shoulder
M00.219 Other streptococcal arthritis, unspecified shoulder
M00.221 Other streptococcal arthritis, right elbow
M00.222 Other streptococcal arthritis, left elbow
M00.229 Other streptococcal arthritis, unspecified elbow
M00.231 Other streptococcal arthritis, right wrist
M00.232 Other streptococcal arthritis, left wrist
M00.239 Other streptococcal arthritis, unspecified wrist
M00.241 Other streptococcal arthritis, right hand
M00.242 Other streptococcal arthritis, left hand
M00.249 Other streptococcal arthritis, unspecified hand
M00.251 Other streptococcal arthritis, right hip
M00.252 Other streptococcal arthritis, left hip
M00.259 Other streptococcal arthritis, unspecified hip
M00.261 Other streptococcal arthritis, right knee
M00.262 Other streptococcal arthritis, left knee
M00.269 Other streptococcal arthritis, unspecified knee
M00.271 Other streptococcal arthritis, right ankle and foot
M00.272 Other streptococcal arthritis, left ankle and foot
M00.279 Other streptococcal arthritis, unspecified ankle and foot
M00.28 Other streptococcal arthritis, vertebrae
M00.29 Other streptococcal polyarthritis
M00.80 Arthritis due to other bacteria, unspecified joint
M00.811 Arthritis due to other bacteria, right shoulder
M00.812 Arthritis due to other bacteria, left shoulder
M00.819 Arthritis due to other bacteria, unspecified shoulder
M00.821 Arthritis due to other bacteria, right elbow
M00.822 Arthritis due to other bacteria, left elbow
M00.829 Arthritis due to other bacteria, unspecified elbow
M00.831 Arthritis due to other bacteria, right wrist
M00.832 Arthritis due to other bacteria, left wrist
M00.839 Arthritis due to other bacteria, unspecified wrist
M00.841 Arthritis due to other bacteria, right hand
M00.842 Arthritis due to other bacteria, left hand
M00.849 Arthritis due to other bacteria, unspecified hand
M00.851 Arthritis due to other bacteria, right hip
M00.852 Arthritis due to other bacteria, left hip
M00.859 Arthritis due to other bacteria, unspecified hip
M00.861 Arthritis due to other bacteria, right knee
M00.862 Arthritis due to other bacteria, left knee
M00.869 Arthritis due to other bacteria, unspecified knee
M00.871 Arthritis due to other bacteria, right ankle and foot
M00.872 Arthritis due to other bacteria, left ankle and foot
M00.879 Arthritis due to other bacteria, unspecified ankle and foot
M00.88 Arthritis due to other bacteria, vertebrae
M00.89 Polyarthritis due to other bacteria
M00.9 Pyogenic arthritis, unspecified
M01.X0 Direct infection of unspecified joint in infectious and parasitic diseases classified elsewhere
M01.X11 Direct infection of right shoulder in infectious and parasitic diseases classified elsewhere
M01.X12 Direct infection of left shoulder in infectious and parasitic diseases classified elsewhere
M01.X19 Direct infection of unspecified shoulder in infectious and parasitic diseases classified elsewhere
M01.X21 Direct infection of right elbow in infectious and parasitic diseases classified elsewhere
M01.X22 Direct infection of left elbow in infectious and parasitic diseases classified elsewhere
M01.X29 Direct infection of unspecified elbow in infectious and parasitic diseases classified elsewhere
M01.X31 Direct infection of right wrist in infectious and parasitic diseases classified elsewhere
M01.X32 Direct infection of left wrist in infectious and parasitic diseases classified elsewhere
M01.X39 Direct infection of unspecified wrist in infectious and parasitic diseases classified elsewhere
M01.X41 Direct infection of right hand in infectious and parasitic diseases classified elsewhere
M01.X42 Direct infection of left hand in infectious and parasitic diseases classified elsewhere
M01.X49 Direct infection of unspecified hand in infectious and parasitic diseases classified elsewhere
M01.X51 Direct infection of right hip in infectious and parasitic diseases classified elsewhere
M01.X52 Direct infection of left hip in infectious and parasitic diseases classified elsewhere
M01.X59 Direct infection of unspecified hip in infectious and parasitic diseases classified elsewhere
M01.X61 Direct infection of right knee in infectious and parasitic diseases classified elsewhere
M01.X62 Direct infection of left knee in infectious and parasitic diseases classified elsewhere
M01.X69 Direct infection of unspecified knee in infectious and parasitic diseases classified elsewhere
M01.X71 Direct infection of right ankle and foot in infectious and parasitic diseases classified elsewhere
M01.X72 Direct infection of left ankle and foot in infectious and parasitic diseases classified elsewhere
M01.X79 Direct infection of unspecified ankle and foot in infectious and parasitic diseases classified elsewhere
M01.X8 Direct infection of vertebrae in infectious and parasitic diseases classified elsewhere
M01.X9 Direct infection of multiple joints in infectious and parasitic diseases classified elsewhere
T84.50XA Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter
T84.50XD Infection and inflammatory reaction due to unspecified internal joint prosthesis, subsequent encounter
T84.50XS Infection and inflammatory reaction due to unspecified internal joint prosthesis, sequela
T84.51XA Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter
T84.51XD Infection and inflammatory reaction due to internal right hip prosthesis, subsequent encounter
T84.51XS Infection and inflammatory reaction due to internal right hip prosthesis, sequela
T84.52XA Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter
T84.52XD Infection and inflammatory reaction due to internal left hip prosthesis, subsequent encounter
T84.52XS Infection and inflammatory reaction due to internal left hip prosthesis, sequela
T84.53XA Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter
T84.53XD Infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter
T84.53XS Infection and inflammatory reaction due to internal right knee prosthesis, sequela
T84.54XA Infection and inflammatory reaction due to internal left knee prosthesis, initial encounter
T84.54XD Infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter
T84.54XS Infection and inflammatory reaction due to internal left knee prosthesis, sequela
T84.59XA Infection and inflammatory reaction due to other internal joint prosthesis, initial encounter
T84.59XD Infection and inflammatory reaction due to other internal joint prosthesis, subsequent encounter
T84.59XS Infection and inflammatory reaction due to other internal joint prosthesis, sequela
T84.60XA Infection and inflammatory reaction due to internal fixation device of unspecified site, initial encounter
T84.60XD Infection and inflammatory reaction due to internal fixation device of unspecified site, subsequent encounter
T84.60XS Infection and inflammatory reaction due to internal fixation device of unspecified site, sequela
T84.610A Infection and inflammatory reaction due to internal fixation device of right humerus, initial encounter
T84.610D Infection and inflammatory reaction due to internal fixation device of right humerus, subsequent encounter
T84.610S Infection and inflammatory reaction due to internal fixation device of right humerus, sequela
T84.611A Infection and inflammatory reaction due to internal fixation device of left humerus, initial encounter
T84.611D Infection and inflammatory reaction due to internal fixation device of left humerus, subsequent encounter
T84.611S Infection and inflammatory reaction due to internal fixation device of left humerus, sequela
T84.612A Infection and inflammatory reaction due to internal fixation device of right radius, initial encounter
T84.612D Infection and inflammatory reaction due to internal fixation device of right radius, subsequent encounter
T84.612S Infection and inflammatory reaction due to internal fixation device of right radius, sequela
T84.613A Infection and inflammatory reaction due to internal fixation device of left radius, initial encounter
T84.613D Infection and inflammatory reaction due to internal fixation device of left radius, subsequent encounter
T84.613S Infection and inflammatory reaction due to internal fixation device of left radius, sequela
T84.614A Infection and inflammatory reaction due to internal fixation device of right ulna, initial encounter
T84.614D Infection and inflammatory reaction due to internal fixation device of right ulna, subsequent encounter
T84.614S Infection and inflammatory reaction due to internal fixation device of right ulna, sequela
T84.615A Infection and inflammatory reaction due to internal fixation device of left ulna, initial encounter
T84.615D Infection and inflammatory reaction due to internal fixation device of left ulna, subsequent encounter
T84.615S Infection and inflammatory reaction due to internal fixation device of left ulna, sequela
T84.619A Infection and inflammatory reaction due to internal fixation device of unspecified bone of arm, initial encounter
T84.619D Infection and inflammatory reaction due to internal fixation device of unspecified bone of arm, subsequent encounter
T84.619S Infection and inflammatory reaction due to internal fixation device of unspecified bone of arm, sequela
T84.620A Infection and inflammatory reaction due to internal fixation device of right femur, initial encounter
T84.620D Infection and inflammatory reaction due to internal fixation device of right femur, subsequent encounter
T84.620S Infection and inflammatory reaction due to internal fixation device of right femur, sequela
T84.621A Infection and inflammatory reaction due to internal fixation device of left femur, initial encounter
T84.621D Infection and inflammatory reaction due to internal fixation device of left femur, subsequent encounter
T84.621S Infection and inflammatory reaction due to internal fixation device of left femur, sequela
T84.622A Infection and inflammatory reaction due to internal fixation device of right tibia, initial encounter
T84.622D Infection and inflammatory reaction due to internal fixation device of right tibia, subsequent encounter
T84.622S Infection and inflammatory reaction due to internal fixation device of right tibia, sequela
T84.623A Infection and inflammatory reaction due to internal fixation device of left tibia, initial encounter
T84.623D Infection and inflammatory reaction due to internal fixation device of left tibia, subsequent encounter
T84.623S Infection and inflammatory reaction due to internal fixation device of left tibia, sequela
T84.624A Infection and inflammatory reaction due to internal fixation device of right fibula, initial encounter
T84.624D Infection and inflammatory reaction due to internal fixation device of right fibula, subsequent encounter
T84.624S Infection and inflammatory reaction due to internal fixation device of right fibula, sequela
T84.625A Infection and inflammatory reaction due to internal fixation device of left fibula, initial encounter
T84.625D Infection and inflammatory reaction due to internal fixation device of left fibula, subsequent encounter
T84.625S Infection and inflammatory reaction due to internal fixation device of left fibula, sequela
T84.629A Infection and inflammatory reaction due to internal fixation device of unspecified bone of leg, initial encounter
T84.629D Infection and inflammatory reaction due to internal fixation device of unspecified bone of leg, subsequent encounter
T84.629S Infection and inflammatory reaction due to internal fixation device of unspecified bone of leg, sequela
T84.63XA Infection and inflammatory reaction due to internal fixation device of spine, initial encounter
T84.63XD Infection and inflammatory reaction due to internal fixation device of spine, subsequent encounter
T84.63XS Infection and inflammatory reaction due to internal fixation device of spine, sequela
T84.69XA Infection and inflammatory reaction due to internal fixation device of other site, initial encounter
T84.69XD Infection and inflammatory reaction due to internal fixation device of other site, subsequent encounter
T84.69XS Infection and inflammatory reaction due to internal fixation device of other site, sequela
T84.7XXA Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, initial encounter
T84.7XXD Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, subsequent encounter
T84.7XXS Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, sequela

Group 11

(14 Codes)
Group 11 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 11: Codes -Non-Urogenital/ Anogenital Cutaneous/ Mucocutaneous Lesion Panels.

 Group 11 Codes
Code Description
B00.0 Eczema herpeticum
B00.1 Herpesviral vesicular dermatitis
B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis
B00.59 Other herpesviral disease of eye
B01.81 Varicella keratitis
B01.9 Varicella without complication
B02.30 Zoster ocular disease, unspecified
B02.31 Zoster conjunctivitis
B02.32 Zoster iridocyclitis
B02.33 Zoster keratitis
B02.34 Zoster scleritis
B02.39 Other herpes zoster eye disease
B02.7 Disseminated zoster
B02.8 Zoster with other complications

Group 12

(1 Code)
Group 12 Paragraph

These are the diagnosis codes corresponding to coverage of CPT/ HCPCS Codes Group 12: Codes-Onychomycosis Panels. 

 Group 12 Codes
Code Description
B35.1 Tinea unguium
N/A

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

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Group 1

Group 1 Paragraph

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 Group 1 Codes

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N/A

ICD-10-PCS Codes

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Group 1

Group 1 Paragraph

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 Group 1 Codes

N/A

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.

Code Description

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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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Other Coding Information

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Group 1

Group 1 Paragraph

N/A

 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
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
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
07/01/2025 R32

Revision Effective: 07/01/2025

Revision Explanation: Under CPT/HCPCS Codes Group 1: Codes deleted 0240U and 0241U. Under CPT/HCPCS Codes Group 6: Codes added 0563U and 0564U. This revision is due to the 2025 Q3 CPT/HCPCS Code Update and is effective 7/1/2025.

Under ICD-10 Codes that Support Medical Necessity Group 11: Codes added B01.9, B01.81, B02.7, B02.8, B02.31, B02.33, B02.34, B02.30, B02.32, B02.39. This revision is effective 5/27/2025.
05/29/2025 R31

Revision Effective: 05/29/2025

Revision Explanation: Under CPT/HCPCS Codes Group 9: Paragraph revised the broken hyperlink.
01/01/2025 R30

Revision Effective: 01/01/2025

Revision Explanation: Under CPT/HCPCS Codes Group 6: Codes added 0528U. This revision is due to the 2025 Annual/Q1 CPT/HCPCS Code Update and is effective 1/1/2025.
01/01/2025 R29

Revision Effective: 01/01/2025 

Revision Explanation: Under CPT/HCPCS Codes Group 5: Codes deleted 0352U and added 81515 and 0527U. Under CPT/HCPCS Codes Group 8: Codes the description was revised for 87624. Added 87513, 87564, 87594, and 87626. Under CPT/HCPCS Codes Group 11: Codes added 0527U. This revision is due to the 2025 Annual/Q1 CPT/HCPCS Code Update and is effective 1/1/2025.
12/05/2024 R28

Revision Effective: 12/05/2024

Revision Explanation: Corrected the policy number in the article text.
12/05/2024 R27

Revision Effective: 12/05/2024

Revision Explanation: Under CPT/HCPCS Codes Group 12: Paragraph added “Onychomycosis Panels: This code is only reimbursed for patients with a confirmed histopathologic diagnosis of an infiltrative/invasive fungal onychomycosis and whose culture (and antifungal susceptibility) of the nail is negative or cannot be performed.” Under CPT/HCPCS Codes Group 12: Codes added 87999. Under CPT/HCPCS Modifiers Group 12: Codes added 59. Under ICD-10 Codes that Support Medical Necessity Group 12: Paragraph added “These are the diagnosis codes corresponding to coverage of CPT/ HCPCS Codes Group 12: Codes-Onychomycosis Panels.” Under ICD-10 Codes that Support Medical Necessity Group 12: Codes added B35.1. This revision is effective 9/13/2024. Also updated the correct LCD policy number to L39038 within the article text.
12/05/2024 R26

Revision Effective: 12/05/2024

Revision Explanation: Under CPT/HCPCS Codes Group 12: Paragraph added “Onychomycosis Panels: This code is only reimbursed for patients with a confirmed histopathologic diagnosis of an infiltrative/invasive fungal onychomycosis and whose culture (and antifungal susceptibility) of the nail is negative or cannot be performed.” Under CPT/HCPCS Codes Group 12: Codes added 87999. Under CPT/HCPCS Modifiers Group 12: Codes added 59. Under ICD-10 Codes that Support Medical Necessity Group 12: Paragraph added “These are the diagnosis codes corresponding to coverage of CPT/ HCPCS Codes Group 12: Codes-Onychomycosis Panels.” Under ICD-10 Codes that Support Medical Necessity Group 12: Codes added B35.1. This revision is effective 9/13/2024. Also updated the correct LCD policy number to L39038 within the article text.
10/01/2024 R25

Revision Effective: 10/01/2024

Revision Explanation: Under ICD-10 Codes that Support Medical Necessity Group 6: Codes added D61.03. Under ICD-10 Codes that Support Medical Necessity Group 7: Codes added D61.03. Under ICD-10 Codes that Support Medical Necessity Group 9: Codes the description was revised for A77.41. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/24.

Under CPT/HCPCS Codes Group 8: Codes added 0483U, 0484U, and 0502U. This revision is due to the 2024 Q4 CPT/HCPCS Code Update and is effective 10/1/2024.

Under CPT/HCPCS Codes Group 8: Codes added 0109U, 0301U, and 0302U. This revision is effective 5/17/2022.
08/01/2024 R24

Revision Effective: 08/01/2024

Revision Explanation: Under CPT/HCPCS Codes Group 11: Paragraph added “Non-Urogenital/Anogenital Cutaneous/Mucocutaneous Lesion Panels: This code is reimbursed under limited circumstances”. Under CPT/HCPCS Codes Group 11: Codes added 87999. Under CPT/HCPCS Modifiers Group 11: Codes added 59. Under ICD-10 Codes that Support Medical Necessity Group 11: Paragraph added “These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 11: Codes -Non-Urogenital/ Anogenital Cutaneous/ Mucocutaneous Lesion Panels”. Under ICD-10 Codes that Support Medical Necessity Group 11: Codes added B00.0, B00.1, B00.2, and B00.59.
07/01/2024 R23

Revision Effective: 07/01/2024

Revison Explanation: 

Under CPT/HCPCS Codes Group 5: Codes deleted 0353U and added 0455U. This is due to the 2024 Q3 CPT/HCPCS Code Update and is effective 7/1/2024.
04/25/2024 R22

Revision Effective: 04/25/2024

Revision Explanation: Annual review, no changes.
04/11/2024 R21

Revision Effective: 04/11/2024

Revision Explanation: Under CPT/HCPCS Codes Group 9: Paragraph deleted “Arthropod” and replaced with “Zoonotic”. Under ICD-10 Codes that Support Medical Necessity Group 9: Paragraph deleted “Arthropod” and replaced with “Zoonotic”. This revision is effective 2/29/2024.
03/07/2024 R20

Revision Effective: 03/07/2024 changes retro effective to 04/17/2022

Revision Explanation: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes deleted Z20.822 and Z20.828. The addition of these codes was done in error. This revision is effective for dates of service on or after 4/17/2022.
01/01/2024 R19

Revision Effective: 01/01/2024

Revision Explanation: Under CPT/HCPCS Group 8: Codes added 87523 and 0429U. This revision is due to the 2024 Annual/Q1 CPT/HCPCS Code Update and is effective 1/1/2024.

Under Article Text added “NOTE: When entering the DEX Z-Code® on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line”. This revision is effective 1/1/2024.

Added group 10 under CPT/HCPCS that was left off in error from revision 17.
11/16/2023 R18

Revision Effective: 11/16/2023

Revision Explanation: Updated LCD Reference Article section.
10/01/2023 R17

Revision Effective: 10/01/2023

Revision Explanation: Under CPT/HCPCS Group 5: Codes added 0402U. This revision is due to the 2023 Q4 CPT/HCPCS Code Update and is effective 10/1/2023.

Under CPT/HCPCS Codes Group 9: Paragraph added “Arthropod Infection Panels: This code is reimbursed under limited circumstances. Note also the additional diagnostic guidance provided by the Centers for Disease Control and Prevention (CDC): https://www.cdc.gov/ticks/tickbornediseases”. Under CPT/HCPCS Group 9: Codes added 87999. Under CPT/HCPCS Modifiers Group 9: Codes added 59. Under ICD-10 Codes that Support Medical Necessity Group 9: Paragraph added “These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 9: Codes - Arthropod Infection Panels”. Under ICD-10 Codes that Support Medical Necessity Group 9: Codes added A77.40, A77.41, A77.49, A79.82, A79.9, A84.89, A84.9, A85.2, A85.8, A86, A93.8, A94, B60.00, B60.09, B60.01, B60.02, B60.03, G04.81, G04.90, R41.82, W57.XXXA, W57.XXXD, and W57.XXXS. This revision is effective 5/8/2023.

Under CPT/HCPCS Codes Group 10: Paragraph added “Joint Infection Panels: This code is reimbursed under limited circumstances”. Under CPT/HCPCS Group 10: Codes added 87999. Under CPT/HCPCS Modifiers Group 10: Codes added 59. Under ICD-10 Codes that Support Medical Necessity Group 10: Paragraph added “These are the diagnosis codes corresponding to coverage of CPT/HCPCS Codes Group 10: Codes - Joint Infection Panels”. Under ICD-10 Codes that Support Medical Necessity Group 10: Codes added A01.04, A02.23, A54.42, M00.00, M00.011, M00.012, M00.019, M00.021, M00.022, M00.029, M00.031, M00.032, M00.039, M00.041, M00.042, M00.049, M00.051, M00.052, M00.059, M00.061, M00.062, M00.069, M00.071, M00.072, M00.079, M00.08, M00.09, M00.10, M00.111,M00.112, M00.119, M00.121, M00.122, M00.129, M00.131, M00.132, M00.139, M00.141, M00.142, M00.149, M00.151, M00.152, M00.159, M00.161, M00.162, M00.169, M00.171, M00.172, M00.179, M00.18, M00.211, M00.212, M00.219, M00.221, M00.222, M00.229, M00.231, M00.232, M00.239, M00.241, M00.242, M00.249, M00.251, M00.252, M00.259, M00.261, M00.262, M00.269, M00.271, M00.272, M00.279, M00.28, M00.29, M00.80, M00.811, M00.812, M00.819, M00.821, M00.822, M00.829, M00.831, M00.832, M00.839, M00.841, M00.842, M00.849, M00.851, M00.852, M00.859, M00.861, M00.862, M00.869, M00.871, M00.872, M00.879, M00.88, M00.89, M00.9, M01.X0, M01.X11, M01.X12, M01.X19, M01.X21, M01.X22, M01.X29, M01.X31, M01.X32, M01.X39, M01.X41, M01.X42, M01.X49, M01.X51, M01.X52, M01.X59, M01.X61, M01.X62, M01.X69, M01.X71, M01.X72, M01.X79, M01.X8, M01.X9, T84.50XS, T84.50XA, T84.50XD, T84.51XA, T84.51XD, T84.51XS, T84.52XA, T84.52XD, T84.52XS, T84.53XA, T84.53XD, T84.53XS, T84.54XA, T84.54XD, T84.54XS, T84.59XA, T84.59XD, T84.59XS, T84.60XA, T84.60XD, T84.60XS, T84.610A, T84.610D, T84.610S, T84.611A, T84.611D, T84.611S, T84.612A, T84.612D, T84.612S, T84.613A, T84.613D, T84.613S, T84.614A, T84.614D, T84.614S, T84.615A, T84.615D, T84.615S, T84.619A, T84.619D, T84.619S, T84.620A, T84.620D, T84.620S, T84.621A, T84.621D, T84.621S, T84.622A, T84.622D, T84.622S, T84.623A, T84.623D, T84.623S, T84.624A, T84.624D, T84.624S, T84.625A, T84.625D, T84.625S, T84.629A, T84.629D, T84.629S, T84.63XA, T84.63XD, T84.63XS, T84.69XA, T84.69XD, T84.69XS, T84.7XXA, T84.7XXD, and T84.7XXS. This revision is effective 8/19/2022.
10/01/2023 R16

Revision Effective: 10/01/2023

Revision Explanation: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added J15.61 and J15.69. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added K35.200, K35.201, K35.209, K35.210, K35.211, K35.219, K63.8211, K63.8212, K63.8219, K63.822, and K63.829. Under ICD-10 Codes that Support Medical Necessity Group 4: Codes added A41.54 and B96.83. Under ICD-10 Codes that Support Medical Necessity Group 6: Codes added J44.81 and J44.89. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/2023.

Under Article Text revised the 4th bullet 2nd sentence to add “and a TA. If an existing CPT® code does not identify the service, it requires the use of CPT® code 87999”. Deleted the 3rd and 4th sentences. Revised the 7th and 10th bullets to remove “DEX Z-Code™” and replaced with “DEX Z-Code®”. This revision is effective on 10/1/2023.
07/01/2023 R15

Revision Effective: 07/01/2023

Revision Explanation: The previous revision effective date of 7/1/2023 is incorrect. The deletion of U0003, U0004, and U0005 from CPT/HCPCS Group 8: Codes is related to the end of the COVID-19 PHE and is effective for dates of service on or after 5/12/2023.
07/01/2023 R14

Revision Effective: 07/01/2023 

Revision Explanation: Under CPT/HCPCS Codes Group 6: Codes added 87999. This revision is effective on 3/24/2023. Under CPT/HCPCS Group 8: Codes deleted U0003, U0004, and U0005. This revision is due to the 2023 Q3 CPT/HCPCS Code Update and is effective on 7/1/2023.
05/04/2023 R13

Revision Effective: 05/04/2023

Revision Explanation: Under CPT/HCPCS Codes Group 8: Codes added 87149, 87150, and 87153 and retroactive effective date of 4/20/2023.
05/04/2023 R12

Revision Effective: 05/04/2023

Revision Explanation: Annual review, no changes 
03/02/2023 R11

Revision Effective: 03/02/2023

Revision Explanation: Under CPT/HCPCS Codes Group 6: Paragraph revised 2nd sentence to add “Per policy, these”. This revision is retroactive effective for dates of service on or after 4/17/2022.
03/02/2023 R10

Revision Effective: 03/02/2023                                                                                                                                                                                                              Revision Explanation: Under CPT/HCPCS Codes Group 1-5: Paragraph revised sentence to add “reimbursed”. Under CPT/HCPCS Codes Group 6: Paragraph revised 1st sentence to add “reimbursed”. Revised 2nd sentence to add “Per policy, these”. Added last sentence. Under CPT/HCPCS Codes Group 7: Paragraph revised 1st sentence to add “reimbursed”. Revised 2nd sentence to add “Per policy, these”. Added last sentence. Under CPT/HCPCS Codes Group 8: Paragraph revised to add “Non-reimbursed”. Revised 1st sentence to add “reimbursed”. Revised 2nd sentence to add “reimbursed”. Under ICD-10 Codes that Support Medical Necessity Group 5: Codes added B37.89 and R30.0. Deleted N93.9 and N95.0. This revision is retroactive effective for dates of service on or after 4/17/2022.
01/01/2023 R9

Revision Effective: 01/01/2023

Revision Explanation: Under CPT/HCPCS Codes Group 5: Codes the description was revised for 87999. Under CPT/HCPCS Codes Group 8: Codes added 87468, 87469, 87478, and 87484. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is effective on January 1, 2023.
12/29/2022 R8

Revision Effective: 12/29/2022

Revision Explanation: Under ICD-10 Codes that Support Medical Necessity Group 5: Codes added L29.2, L29.3, N90.89, N93.0, N93.8, N93.9, N95.0, R10.2, and Z20.2. This revision is retroactive effective for dates of service on or after 4/17/2022.
10/01/2022 R7

Revision Effective: 10/01/2022

Revision Explanation:  Under Article Text revised the thirteenth bullet first sentence to add “for the same (or highly similar) intended use”. Under CPT/HCPCS Codes Group 5: Codes added 87999. This revision is retroactive effective for dates of service on or after 4/17/2022.

Under CPT/HCPCS Codes Group 5: Codes added 0352U and 0353U. Under CPT/HCPCS Codes Group 8: Codes added 87593. This revision is due to the Q4 CPT/HCPCS Code Update and is effective for dates of service on or after 10/1/2022.
10/01/2022 R6

Revision Effective: 10/01/2022

Revision Explanation: Under ICD-10 Codes that Support Medical Necessity Group 5: Code Z72.52 was left off in error from revision 5.
10/01/2022 R5

Revision Effective: 10/01/2022

Revision Explanation: 

Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph revised second sentence to add “POS 19, 21, 22 or 23”. Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph revised second sentence to add “POS 19, 21, 22 or 23”. This revision is retroactive effective for dates of service on or after 5/17/2022.

Under ICD-10 Codes that Support Medical Necessity Group 5: Paragraph added “NOTE: Claims with diagnosis code Z11.3 would be expected to also include a high-risk diagnosis code”. Under ICD-10 Codes that Support Medical Necessity Group 5: Codes added Z11.3, Z33.1, Z33.3, Z72.51, Z72.52, Z72.53, Z72.89. This revision is retroactive effective for dates of service on or after 9/6/2022.

Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added D59.30 and D59.31. Under ICD-10 Codes that Support Medical Necessity Group 4: Codes added D59.30 and D59.31. Under ICD-10 Codes that Support Medical Necessity Group 5: Codes deleted B37.3. Added B37.31, B37.32, and N76.82. Under ICD-10 Codes that Support Medical Necessity Group 6: Codes added D81.82. Under ICD-10 Codes that Support Medical Necessity Group 7: Codes added D81.82. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/2022.
06/02/2022 R4

Revision Effective: 06/02/2022

Revision Explanation: 

Under CPT/HCPCS Codes Group 6: Codes deleted 0151U. Under CPT/HCPCS Codes Group 7: Codes deleted 0097U. This revision is due to the Q2 CPT/HCPCS Code Update and is effective for dates of service on or after 4/1/2022.

Under Article Text revised first and second bullet verbiage to add “or PLA” and deleted third and fourth bullet verbiage. Revised fifth bullet verbiage to add, “and a TA.” Deleted the sixth and seventh bullet verbiage. Added two new bullet verbiages, “Tests that are FDA-approved/cleared and performed in ways consistent with their intended-use labeling directions do not require a Z-code when billed with an appropriate accompanying ICD-10 code. However, the performance of multiple (>1) FDA-approved/cleared molecular Infectious Disease pathogen identification tests on the same date of service (DOS) for the same intended use on the same patient sample is considered as one distinct service. As such, it would require the use of CPT® code 87999. Tests using CPT® code 87999 will require a Z-code and a TA.” And “Add modifier 59 for different species or strains reported by the same code, as allowed by the policy.” Revised Additional Information nineth bullet verbiage to “Places of service (POS) 19, 21, 22, 23 OR” and “(for healthcare POS other than the POS listed in 1 (a).” Under CPT/HCPCS Group 1: Paragraph deleted second sentence. Under CPT/HCPCS Codes Group 1: Codes added 87801. Under CPT/HCPCS Group 2: Paragraph deleted second sentence. Under CPT/HCPCS Group 3: Paragraph deleted second sentence. Under CPT/HCPCS Group 4: Paragraph deleted second sentence. Under CPT/HCPCS Group 5: Paragraph deleted second sentence. Under CPT/HCPCS Group 5: Codes deleted 87623, 87624, and 87625. Under CPT/HCPCS Group 6: Paragraph deleted third sentence. Revised fourth sentence to add “POS 19, 21, 22, 23” and “(for healthcare POS other than those listed in (a).” Under CPT/HCPCS Group 6: Codes added 87801. Under CPT/HCPCS Group 7: Paragraph deleted third sentence. Revised fourth sentence to add “POS 19, 21, 22, 23” and “(for healthcare POS other than those listed in (a).” Under CPT/HCPCS Group 8: Paragraph added verbiage, “Conditionally Non-covered CPT codes: The following CPT codes are NOT covered for a given beneficiary on the same DOS when >1 is billed in combination with another CPT or PLA code from Groups 1-7 for the same intended use. Additionally, the following CPT codes are NOT covered for a given beneficiary on the same DOS when >2 are billed for the same intended use.” Under CPT/HCPCS Group 8: Codes added U0001, U0002, U0003, U0004, U0005, 87471, 87472, 87475, 87476, 87480, 87481, 87482, 87485, 87486, 87487, 87490, 87491, 87492, 87493, 87495, 87496, 87497, 87498, 87501, 87502, 87503, 87510, 87511, 87512, 87516, 87517, 87520, 87521, 87522, 87525, 87526, 87527, 87528, 87529, 87530, 87531, 87532, 87533, 87534, 87535, 87536, 87537, 87538, 87539, 87540, 87541, 87542, 87550, 87551, 87552, 87555, 87556, 87557, 87560, 87561, 87562, 87563, 87580, 87581, 87582, 87590, 87591, 87592, 87623, 87624, 87625, 87634, 87635, 87640, 87641, 87650, 87651, 87652, 87653, 87660, 87661, 87662, 87797, 87798, and 87799. Under CPT/HCPCS Modifiers Group 8: Codes added 59. Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added B60.2. Under ICD-10 Codes that Support Medical Necessity Group 5: Codes added N76.89, N77.1, and N89.8.
06/02/2022 R3

Revision Effective: 06/02/2022

Revision Explanation: Added code J15.1 as it should have been listed under group 1 ICD-10, Removed B00.1 from group 2, and added J44.9 to group 6 as these were to be done under revision 1.
06/02/2022 R2

R2

NOTE: This is the original entry for this Revision:

Revision Effective: 07/16/2022

Revision Explanation: This article will not be effective until the 07/16/2022 as the policy has had an extension to the notice period. The notice period is being extended until 07/15/2022 as there are 2 policies, L37364 and L37348, that need to go through the retirement process that overlaps into this foundational policy.

UPDATE: On 5/19/2022, the Revision Effective Date of this article was changed from 7/16/2022 to 6/2/2022. See the note at the top of the article for more information. 
04/17/2022 R1

R1

Revision Effective: 04/17/2022

Revision Explanation: Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added A37.00, A37.01, A37.10, A37.11, A37.80, A37.81, A37.90, A37.91, A41.81, A41.89, A48.1, A48.2, B25.0, B33.23, B33.24, B59, J05.0, J12.0, J12.2, J12.3, J13, J15.0, J15.1, J15.20, J15.211, J15.212, J15.29, J15.3, J15.4, J15.7, J15.8, J15.9, J16.0, J20.0, J20.1, J20.2, J20.3, J20.4, J20.6, J22, J84.116, J84.117, J84.2, J85.0, J85.1, J85.2, J85.3, T86.33, and T86.812. Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph added the verbiage “Targeted”. Under ICD-10 Codes that Support Medical Necessity Group 2: Codes added A08.31, A08.32, A32.11, A32.12, A32.7, K51.414, K92.1, R10.11, R10.12, R10.13 and T86.852. Deleted B20, K50.018, K50.111, K50.818, K50.918, K51.018, K51.218, K51.318, K51.518, and K51.818. Under ICD-10 Codes that Support Medical Necessity Group 3: Codes added R41.82 and R50.9. Deleted B00.1. Under ICD-10 Codes that Support Medical Necessity Group 4: Codes deleted E10.69, E11.69, and E13.69. Under ICD-10 Codes that Support Medical Necessity Group 5: Codes added O98.711, O98.712, and O98.713. Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph added verbiage “For testing in POS other than POS 21 or 23” to beginning of second sentence and “(once per transplant)” to third sentence. Under ICD-10 Codes that Support Medical Necessity Group 6: Codes added E08.43, E10.43, E11.43, and E13.43. Deleted A37.00, A37.01, A37.10, A37.11, A37.80, A37.81, A37.90, A37.91, A41.81, A41.89, A41.9, A48.1, A48.2, B25.0, B25.1, B25.2, B25.8, B33.23, B33.24, B59, B97.21, B97.29, D80.7, J05.0, J12.0, J12.2, J12.3, J12.81, J12.82, J12.89, J12.9, J13, J15.0, J15.1, J15.20, J15.211, J15.212, J15.29, J15.3, J15.4, J15.7, J15.8, J15.9, J16.0, J16.8, J18.1, J20.0, J20.1, J20.2, J20.3, J20.4, J20.5, J20.6, J20.8, J20.9, J21.9, J22, J44.0, J44.1, J45.31, J45.32, J45.41, J45.42, J45.51, J45.52, J45.901, J45.902, J84.116, J84.117, J84.2, J85.0, J85.1, J85.2, J85.3, R65.20, R65.21, R78.81, T86.33, and T86.812. Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph added verbiage “For testing in POS other than POS 21 or 23” to beginning of second sentence and “(once per transplant)” to third sentence. Under ICD-10 Codes that Support Medical Necessity Group 7: Codes deleted A00.0, A00.1, A00.9, A01.00, A01.09, A01.1, A01.2, A01.3, A02.0, A02.1, A02.8, A03.0, A03.1, A03.2, A03.3, A03.8, A04.0, A04.1, A04.2, A04.3, A04.5, A04.6, A04.71, A04.72, A04.8, A04.9, A05.0, A05.1, A05.2, A05.3, A05.4, A05.5, A06.0, A06.1, A06.2, A07.1, A07.2, A07.4, A08.0, A08.11, A08.19, A08.2, A08.31, A08.32, A08.39, A08.8, A09, A32.11, A32.12, A32.7, A41.50, A41.51, A41.52, A41.53, A41.59, A41.81, A41.89, A41.9, B25.0, B25.8, D80.7, K50.014, K50.114, K50.814, K50.914. K51.014, K51.214, K51.314, K51.414, K51.514, K51.814, K51.914, K52.1, K56.0, K92.1, M31.19, R10.0, R10.11, R10.12, R10.13, R10.31, R10.32, R10.33, R10.811, R10.812, R10.813, R10.814, R10.815, R10.817, R10.821, R10.822, R10.823, R10.824, R10.825, R10.826, R10.827, R10.829, R10.84, R19.5, R19.7, R50.9, R65.20, R65.21, R78.81, and T86.852. 
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Keywords

  • Multiplex Nucleic Acid Amplification Test
  • NAAT
  • Infectious Disease Panel

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