Superseded Local Coverage Article Billing and Coding

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

A58761

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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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General Information

Source Article ID
N/A
Article ID
A58761
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
12/29/2022
Revision Ending Date
12/31/2022
Retirement Date
N/A
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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 L39044.

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. As such, it would require the use of CPT® code 87999. Tests using CPT® code 87999 will require a Z-Code and a TA.
  • 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

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 1a):

      (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
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

Targeted Respiratory Panels:
These codes are covered under limited circumstances.

Group 1 Codes
Code Description
87631 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 3-5 TARGETS
87636 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]) AND INFLUENZA VIRUS TYPES A AND B, MULTIPLEX AMPLIFIED PROBE TECHNIQUE
87637 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), INFLUENZA VIRUS TYPES A AND B, AND RESPIRATORY SYNCYTIAL VIRUS, MULTIPLEX AMPLIFIED PROBE TECHNIQUE
87801 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE
0240U INFECTIOUS DISEASE (VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC RNA, 3 TARGETS (SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 [SARS-COV-2], INFLUENZA A, INFLUENZA B), UPPER RESPIRATORY SPECIMEN, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED
0241U INFECTIOUS DISEASE (VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC RNA, 4 TARGETS (SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 [SARS-COV-2], INFLUENZA A, INFLUENZA B, RESPIRATORY SYNCYTIAL VIRUS [RSV]), UPPER RESPIRATORY SPECIMEN, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED

Group 2

(1 Code)
Group 2 Paragraph

Targeted Gastrointestinal Panels:
This code is covered under limited circumstances.

Group 2 Codes
Code Description
87505 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 3-5 TARGETS

Group 3

(1 Code)
Group 3 Paragraph

Meningoencephalitis Panels:
This code is covered under limited circumstances.

Group 3 Codes
Code Description
87483 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CENTRAL NERVOUS SYSTEM PATHOGEN (EG, NEISSERIA MENINGITIDIS, STREPTOCOCCUS PNEUMONIAE, LISTERIA, HAEMOPHILUS INFLUENZAE, E. COLI, STREPTOCOCCUS AGALACTIAE, ENTEROVIRUS, HUMAN PARECHOVIRUS, HERPES SIMPLEX VIRUS TYPE 1 AND 2, HUMAN HERPESVIRUS 6, CYTOMEGALOVIRUS, VARICELLA ZOSTER VIRUS, CRYPTOCOCCUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 12-25 TARGETS

Group 4

(1 Code)
Group 4 Paragraph

Bloodstream Infection Panels:
This code is covered under limited circumstances.

Group 4 Codes
Code Description
87154 CULTURE, TYPING; IDENTIFICATION OF BLOOD PATHOGEN AND RESISTANCE TYPING, WHEN PERFORMED, BY NUCLEIC ACID (DNA OR RNA) PROBE, MULTIPLEXED AMPLIFIED PROBE TECHNIQUE INCLUDING MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, PER CULTURE OR ISOLATE, 6 OR MORE TARGETS

Group 5

(7 Codes)
Group 5 Paragraph

Urogenital/Anogenital Panels:
These codes are covered under limited circumstances.

Group 5 Codes
Code Description
81513 INFECTIOUS DISEASE, BACTERIAL VAGINOSIS, QUANTITATIVE REAL-TIME AMPLIFICATION OF RNA MARKERS FOR ATOPOBIUM VAGINAE, GARDNERELLA VAGINALIS, AND LACTOBACILLUS SPECIES, UTILIZING VAGINAL-FLUID SPECIMENS, ALGORITHM REPORTED AS A POSITIVE OR NEGATIVE RESULT FOR BACTERIAL VAGINOSIS
81514 INFECTIOUS DISEASE, BACTERIAL VAGINOSIS AND VAGINITIS, QUANTITATIVE REAL-TIME AMPLIFICATION OF DNA MARKERS FOR GARDNERELLA VAGINALIS, ATOPOBIUM VAGINAE, MEGASPHAERA TYPE 1, BACTERIAL VAGINOSIS ASSOCIATED BACTERIA-2 (BVAB-2), AND LACTOBACILLUS SPECIES (L. CRISPATUS AND L. JENSENII), UTILIZING VAGINAL-FLUID SPECIMENS, ALGORITHM REPORTED AS A POSITIVE OR NEGATIVE FOR HIGH LIKELIHOOD OF BACTERIAL VAGINOSIS, INCLUDES SEPARATE DETECTION OF TRICHOMONAS VAGINALIS AND/OR CANDIDA SPECIES (C. ALBICANS, C. TROPICALIS, C. PARAPSILOSIS, C. DUBLINIENSIS), CANDIDA GLABRATA, CANDIDA KRUSEI, WHEN REPORTED
87800 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; DIRECT PROBE(S) TECHNIQUE
87801 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE
87999 UNLISTED MICROBIOLOGY PROCEDURE
0352U INFECTIOUS DISEASE (BACTERIAL VAGINOSIS AND VAGINITIS), MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FOR DETECTION OF BACTERIAL VAGINOSIS-ASSOCIATED BACTERIA (BVAB-2, ATOPOBIUM VAGINAE, AND MEGASPHERA TYPE 1), ALGORITHM REPORTED AS DETECTED OR NOT DETECTED AND SEPARATE DETECTION OF CANDIDA SPECIES (C. ALBICANS, C. TROPICALIS, C. PARAPSILOSIS, C. DUBLINIENSIS), CANDIDA GLABRATA/CANDIDA KRUSEI, AND TRICHOMONAS VAGINALIS, VAGINAL-FLUID SPECIMEN, EACH RESULT REPORTED AS DETECTED OR NOT DETECTED
0353U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA), CHLAMYDIA TRACHOMATIS AND NEISSERIA GONORRHOEAE, MULTIPLEX AMPLIFIED PROBE TECHNIQUE, URINE, VAGINAL, PHARYNGEAL, OR RECTAL, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED

Group 6

(7 Codes)
Group 6 Paragraph

Expanded Respiratory and Pneumonia Panels:

Covered under limited circumstances. These codes are covered in beneficiaries with serious or critical illness or at imminent risk of becoming seriously or critically ill, immunodeficiency, and/or severe underlying condition contributory to testing using an expanded syndromic panel.

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 those listed in a):

(1) For immune-competent beneficiaries, the test must be ordered by an Infectious Disease Specialist or Pulmonologist 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), or Pulmonologist 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.

Group 6 Codes
Code Description
87632 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 6-11 TARGETS
87633 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 12-25 TARGETS
87801 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE
0115U RESPIRATORY INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), 18 VIRAL TYPES AND SUBTYPES AND 2 BACTERIAL TARGETS, AMPLIFIED PROBE TECHNIQUE, INCLUDING MULTIPLEX REVERSE TRANSCRIPTION FOR RNA TARGETS, EACH ANALYTE REPORTED AS DETECTED OR NOT DETECTED
0202U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC NUCLEIC ACID (DNA OR RNA), 22 TARGETS INCLUDING SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2), QUALITATIVE RT-PCR, NASOPHARYNGEAL SWAB, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED
0223U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION), PATHOGEN-SPECIFIC NUCLEIC ACID (DNA OR RNA), 22 TARGETS INCLUDING SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2), QUALITATIVE RT-PCR, NASOPHARYNGEAL SWAB, EACH PATHOGEN REPORTED AS DETECTED OR NOT DETECTED
0225U INFECTIOUS DISEASE (BACTERIAL OR VIRAL RESPIRATORY TRACT INFECTION) PATHOGEN-SPECIFIC DNA AND RNA, 21 TARGETS, INCLUDING SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2), AMPLIFIED PROBE TECHNIQUE, INCLUDING MULTIPLEX REVERSE TRANSCRIPTION FOR RNA TARGETS, EACH ANALYTE REPORTED AS DETECTED OR NOT DETECTED

Group 7

(2 Codes)
Group 7 Paragraph

Expanded Gastrointestinal Panels:

Covered under limited circumstances. These codes are covered in beneficiaries with serious or critical illness or at imminent risk of becoming seriously or critically ill, immunodeficiency, and/or severe underlying condition contributory to testing using an expanded syndromic panel.

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 those listed in a):

(1) For immune-competent beneficiaries, the test must be ordered by an Infectious Disease Specialist or Gastroenterologist 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), or Gastroenterologist 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.

Group 7 Codes
Code Description
87506 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 6-11 TARGETS
87507 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 12-25 TARGETS

Group 8

(86 Codes)
Group 8 Paragraph

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.

Group 8 Codes
Code Description
87471 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, AMPLIFIED PROBE TECHNIQUE
87472 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, QUANTIFICATION
87475 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI, DIRECT PROBE TECHNIQUE
87476 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BORRELIA BURGDORFERI, AMPLIFIED PROBE TECHNIQUE
87480 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, DIRECT PROBE TECHNIQUE
87481 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, AMPLIFIED PROBE TECHNIQUE
87482 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, QUANTIFICATION
87485 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE, DIRECT PROBE TECHNIQUE
87486 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE
87487 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA PNEUMONIAE, QUANTIFICATION
87490 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, DIRECT PROBE TECHNIQUE
87491 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE
87492 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, QUANTIFICATION
87493 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CLOSTRIDIUM DIFFICILE, TOXIN GENE(S), AMPLIFIED PROBE TECHNIQUE
87495 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, DIRECT PROBE TECHNIQUE
87496 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, AMPLIFIED PROBE TECHNIQUE
87497 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CYTOMEGALOVIRUS, QUANTIFICATION
87498 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ENTEROVIRUS, AMPLIFIED PROBE TECHNIQUE, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87501 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, INCLUDES REVERSE TRANSCRIPTION, WHEN PERFORMED, AND AMPLIFIED PROBE TECHNIQUE, EACH TYPE OR SUBTYPE
87502 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST 2 TYPES OR SUB-TYPES
87503 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, EACH ADDITIONAL INFLUENZA VIRUS TYPE OR SUB-TYPE BEYOND 2 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
87510 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS, DIRECT PROBE TECHNIQUE
87511 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS, AMPLIFIED PROBE TECHNIQUE
87512 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS, QUANTIFICATION
87516 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, AMPLIFIED PROBE TECHNIQUE
87517 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS B VIRUS, QUANTIFICATION
87520 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, DIRECT PROBE TECHNIQUE
87521 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, AMPLIFIED PROBE TECHNIQUE, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87522 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87525 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, DIRECT PROBE TECHNIQUE
87526 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, AMPLIFIED PROBE TECHNIQUE
87527 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HEPATITIS G, QUANTIFICATION
87528 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, DIRECT PROBE TECHNIQUE
87529 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, AMPLIFIED PROBE TECHNIQUE
87530 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES SIMPLEX VIRUS, QUANTIFICATION
87531 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, DIRECT PROBE TECHNIQUE
87532 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, AMPLIFIED PROBE TECHNIQUE
87533 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES VIRUS-6, QUANTIFICATION
87534 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, DIRECT PROBE TECHNIQUE
87535 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, AMPLIFIED PROBE TECHNIQUE, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87536 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87537 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, DIRECT PROBE TECHNIQUE
87538 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, AMPLIFIED PROBE TECHNIQUE, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87539 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, QUANTIFICATION, INCLUDES REVERSE TRANSCRIPTION WHEN PERFORMED
87540 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA, DIRECT PROBE TECHNIQUE
87541 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA, AMPLIFIED PROBE TECHNIQUE
87542 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); LEGIONELLA PNEUMOPHILA, QUANTIFICATION
87550 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES, DIRECT PROBE TECHNIQUE
87551 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES, AMPLIFIED PROBE TECHNIQUE
87552 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES, QUANTIFICATION
87555 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCULOSIS, DIRECT PROBE TECHNIQUE
87556 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCULOSIS, AMPLIFIED PROBE TECHNIQUE
87557 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA TUBERCULOSIS, QUANTIFICATION
87560 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INTRACELLULARE, DIRECT PROBE TECHNIQUE
87561 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INTRACELLULARE, AMPLIFIED PROBE TECHNIQUE
87562 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INTRACELLULARE, QUANTIFICATION
87563 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA GENITALIUM, AMPLIFIED PROBE TECHNIQUE
87580 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIAE, DIRECT PROBE TECHNIQUE
87581 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE
87582 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOPLASMA PNEUMONIAE, QUANTIFICATION
87590 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, DIRECT PROBE TECHNIQUE
87591 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE
87592 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, QUANTIFICATION
87593 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ORTHOPOXVIRUS (EG, MONKEYPOX VIRUS, COWPOX VIRUS, VACCINIA VIRUS), AMPLIFIED PROBE TECHNIQUE, EACH
87623 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HUMAN PAPILLOMAVIRUS (HPV), LOW-RISK TYPES (EG, 6, 11, 42, 43, 44)
87624 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HUMAN PAPILLOMAVIRUS (HPV), HIGH-RISK TYPES (EG, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
87625 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HUMAN PAPILLOMAVIRUS (HPV), TYPES 16 AND 18 ONLY, INCLUDES TYPE 45, IF PERFORMED
87634 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY SYNCYTIAL VIRUS, AMPLIFIED PROBE TECHNIQUE
87635 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE
87640 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, AMPLIFIED PROBE TECHNIQUE
87641 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE
87650 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, DIRECT PROBE TECHNIQUE
87651 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE
87652 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP A, QUANTIFICATION
87653 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STREPTOCOCCUS, GROUP B, AMPLIFIED PROBE TECHNIQUE
87660 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); TRICHOMONAS VAGINALIS, DIRECT PROBE TECHNIQUE
87661 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); TRICHOMONAS VAGINALIS, AMPLIFIED PROBE TECHNIQUE
87662 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ZIKA VIRUS, AMPLIFIED PROBE TECHNIQUE
87797 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; DIRECT PROBE TECHNIQUE, EACH ORGANISM
87798 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM
87799 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM
U0001 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL
U0002 2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC
U0003 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE, MAKING USE OF HIGH THROUGHPUT TECHNOLOGIES AS DESCRIBED BY CMS-2020-01-R
U0004 2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC, MAKING USE OF HIGH THROUGHPUT TECHNOLOGIES AS DESCRIBED BY CMS-2020-01-R
U0005 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED PROBE TECHNIQUE, CDC OR NON-CDC, MAKING USE OF HIGH THROUGHPUT TECHNOLOGIES, COMPLETED WITHIN 2 CALENDAR DAYS FROM DATE OF SPECIMEN COLLECTION (LIST SEPARATELY IN ADDITION TO EITHER HCPCS CODE U0003 OR U0004) AS DESCRIBED BY CMS-2020-01-R2
N/A

CPT/HCPCS Modifiers

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.
N/A

ICD-10-CM Codes that Support Medical Necessity

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
J15.7 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
Z20.822 Contact with and (suspected) exposure to COVID-19
Z20.828 Contact with and (suspected) exposure to other viral communicable diseases
U07.1 COVID-19

Group 2

(104 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
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
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

(76 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
A41.59 Other Gram-negative sepsis
A41.9 Sepsis, unspecified organism
A54.86 Gonococcal sepsis
A79.82 Anaplasmosis [A. phagocytophilum]
B37.7 Candidal sepsis
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
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
N93.9 Abnormal uterine and vaginal bleeding, unspecified
N95.0 Postmenopausal 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
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

(124 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
D61.09 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
J44.9 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

(161 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
D61.09 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
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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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

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

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

Revision History Date Revision History Number Revision History Explanation
12/29/2022 R5

Posted 12/29/2022 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 R4

Posted 10/27/2022 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 04/17/2022. 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 10/01/2022.

10/01/2022 R3

Posted 09/29/2022 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 05/17/2022.

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 09/06/2022.

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 10/01/2022. Review completed 08/30/2022.

05/17/2022 R2

Posted 05/26/2022 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 04/01/2022.

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: added B60.2, Group 5: added N76.89, N77.1, and N89.8. This revision is effective 05/17/2022.

04/17/2022 R1

Posted 04/14/2022 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. Review completed 03/10/2022.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
10/18/2023 10/01/2023 - N/A Currently in Effect View
08/23/2023 10/01/2023 - N/A Superseded View
07/19/2023 07/27/2023 - 09/30/2023 Superseded View
04/21/2023 04/20/2023 - 07/26/2023 Superseded View
03/22/2023 03/30/2023 - 04/19/2023 Superseded View
01/20/2023 01/01/2023 - 03/29/2023 Superseded View
12/22/2022 12/29/2022 - 12/31/2022 Superseded You are here
10/18/2022 10/01/2022 - 12/28/2022 Superseded View
09/21/2022 10/01/2022 - N/A Superseded View
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Keywords

  • Molecular Syndromic Panels
  • NAAT
  • Infectious Disease Panel