Coding Information

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 999 Not Applicable CPT/HCPCS Codes: Group 1 Paragraph: N/A Group 1 CPT Codes: 86790 ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED 86794 ANTIBODY; ZIKA VIRUS, IGM 87662 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); ZIKA VIRUS, AMPLIFIED PROBE TECHNIQUE 87798 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM 87801 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE ICD-10 Codes That Are Covered A92.5 Zika virus disease B30.9 Viral conjunctivitis, unspecified M25.50 Pain in unspecified joint M25.511 Pain in right shoulder M25.512 Pain in left shoulder M25.519 Pain in unspecified shoulder M25.521 Pain in right elbow M25.522 Pain in left elbow M25.529 Pain in unspecified elbow M25.531 Pain in right wrist M25.532 Pain in left wrist M25.539 Pain in unspecified wrist M25.551 Pain in right hip M25.552 Pain in left hip M25.559 Pain in unspecified hip M25.561 Pain in right knee M25.562 Pain in left knee M25.569 Pain in unspecified knee M25.571 Pain in right ankle and joints of right foot M25.572 Pain in left ankle and joints of left foot M25.579 Pain in unspecified ankle and joints of unspecified foot O09.00 Supervision of pregnancy with history of infertility, unspecified trimester O09.01 Supervision of pregnancy with history of infertility, first trimester O09.02 Supervision of pregnancy with history of infertility, second trimester O09.03 Supervision of pregnancy with history of infertility, third trimester O09.10 Supervision of pregnancy with history of ectopic pregnancy, unspecified trimester O09.11 Supervision of pregnancy with history of ectopic pregnancy, first trimester O09.12 Supervision of pregnancy with history of ectopic pregnancy, second trimester O09.13 Supervision of pregnancy with history of ectopic pregnancy, third trimester O09.211 Supervision of pregnancy with history of pre-term labor, first trimester O09.212 Supervision of pregnancy with history of pre-term labor, second trimester O09.213 Supervision of pregnancy with history of pre-term labor, third trimester O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester O09.291 Supervision of pregnancy with other poor reproductive or obstetric history, first trimester O09.292 Supervision of pregnancy with other poor reproductive or obstetric history, second trimester O09.293 Supervision of pregnancy with other poor reproductive or obstetric history, third trimester O09.299 Supervision of pregnancy with other poor reproductive or obstetric history, unspecified trimester O09.30 Supervision of pregnancy with insufficient antenatal care, unspecified trimester O09.31 Supervision of pregnancy with insufficient antenatal care, first trimester O09.32 Supervision of pregnancy with insufficient antenatal care, second trimester O09.33 Supervision of pregnancy with insufficient antenatal care, third trimester O09.40 Supervision of pregnancy with grand multiparity, unspecified trimester O09.41 Supervision of pregnancy with grand multiparity, first trimester O09.42 Supervision of pregnancy with grand multiparity, second trimester O09.43 Supervision of pregnancy with grand multiparity, third trimester O09.511 Supervision of elderly primigravida, first trimester O09.512 Supervision of elderly primigravida, second trimester O09.513 Supervision of elderly primigravida, third trimester O09.519 Supervision of elderly primigravida, unspecified trimester O09.521 Supervision of elderly multigravida, first trimester O09.522 Supervision of elderly multigravida, second trimester O09.523 Supervision of elderly multigravida, third trimester O09.529 Supervision of elderly multigravida, unspecified trimester O09.611 Supervision of young primigravida, first trimester O09.612 Supervision of young primigravida, second trimester O09.613 Supervision of young primigravida, third trimester O09.619 Supervision of young primigravida, unspecified trimester O09.621 Supervision of young multigravida, first trimester O09.622 Supervision of young multigravida, second trimester O09.623 Supervision of young multigravida, third trimester O09.629 Supervision of young multigravida, unspecified trimester O09.70 Supervision of high risk pregnancy due to social problems, unspecified trimester O09.71 Supervision of high risk pregnancy due to social problems, first trimester O09.72 Supervision of high risk pregnancy due to social problems, second trimester O09.73 Supervision of high risk pregnancy due to social problems, third trimester O09.811 Supervision of pregnancy resulting from assisted reproductive technology, first trimester O09.812 Supervision of pregnancy resulting from assisted reproductive technology, second trimester O09.813 Supervision of pregnancy resulting from assisted reproductive technology, third trimester O09.819 Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester O09.821 Supervision of pregnancy with history of in utero procedure during previous pregnancy, first trimester O09.822 Supervision of pregnancy with history of in utero procedure during previous pregnancy, second trimester O09.823 Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester O09.829 Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester O09.891 Supervision of other high risk pregnancies, first trimester O09.892 Supervision of other high risk pregnancies, second trimester O09.893 Supervision of other high risk pregnancies, third trimester O09.899 Supervision of other high risk pregnancies, unspecified trimester O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester O09.91 Supervision of high risk pregnancy, unspecified, first trimester O09.92 Supervision of high risk pregnancy, unspecified, second trimester O09.93 Supervision of high risk pregnancy, unspecified, third trimester O28.3 Abnormal ultrasonic finding on antenatal screening of mother O28.4 Abnormal radiological finding on antenatal screening of mother O35.00X1 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 1 O35.00X2 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 2 O35.00X3 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 3 O35.00X4 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 4 O35.00X5 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, fetus 5 O35.00X9 Maternal care for (suspected) central nervous system malformation or damage in fetus, unspecified, other fetus O35.07X1 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 1 O35.07X2 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 2 O35.07X3 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 3 O35.07X4 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 4 O35.07X5 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, fetus 5 O35.07X9 Maternal care for (suspected) central nervous system malformation or damage in fetus, microcephaly, other fetus O35.09X1 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 1 O35.09X2 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 2 O35.09X3 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 3 O35.09X4 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 4 O35.09X5 Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 5 O35.09X9 Maternal care for (suspected) other central nervous system malformation or damage in fetus, other fetus O35.3XX0 Maternal care for (suspected) damage to fetus from viral disease in mother, not applicable or unspecified O35.3XX1 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 1 O35.3XX2 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 2 O35.3XX3 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 3 O35.3XX4 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 4 O35.3XX5 Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 5 O35.3XX9 Maternal care for (suspected) damage to fetus from viral disease in mother, other fetus R21 Rash and other nonspecific skin eruption R50.9 Fever, unspecified Z03.73 Encounter for suspected fetal anomaly ruled out Z03.79 Encounter for other suspected maternal and fetal conditions ruled out Z03.89 Encounter for observation for other suspected diseases and conditions ruled out Z20.821 Contact with and (suspected) exposure to Zika virus Z33.1 Pregnant state, incidental Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester Z34.01 Encounter for supervision of normal first pregnancy, first trimester Z34.02 Encounter for supervision of normal first pregnancy, second trimester Z34.03 Encounter for supervision of normal first pregnancy, third trimester Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester Z34.81 Encounter for supervision of other normal pregnancy, first trimester Z34.82 Encounter for supervision of other normal pregnancy, second trimester Z34.83 Encounter for supervision of other normal pregnancy, third trimester Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester Z36.89 Encounter for other specified antenatal screening ICD-10 Codes That Are Not Covered N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation 10/01/2022 R11 Updated to indicate this article is not an LCD Reference Article. 10/01/2022 R10 The following were made to ICD-10-CM Codes that Support Medical Necessity, Group 1: ICD-10 codes deleted: O35.0XX0; O35.0XX1; O35.0XX2; O35.0XX3; O35.0XX4; O35.0XX5; O35.0XX9 ICD-10 codes added: O3500X1; O3500X2; O3500X3; O3500X4; O3500X5; O3500X9; O3507X1; O3507X2; O3507X3; O3507X4; O3507X5; O3507X9; O3509X1; O3509X2; O3509X3; O3509X4; O3509X5; O3509X9 This revision is due to the annual ICD-10 updates effective 10/1/2022. 10/01/2018 R9 Converted to Billing and Coding article type only. No changes to article content. 10/01/2018 R8 09.05.18: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. The following ICD-10 Codes were added to the ICD-10 Codes that Support Medical Necessity field: Z20.821. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018. 01/01/2018 R7 2018 CPT Coded added effective 01/01/2018: 86794 and 87662 10/01/2017 R6 08/28/2017: Adding Code Z36.89 to replace deleted code Z36 per ICD-10-Coding Update. 10/01/2016 R5 Removal of language: *The use of modifier -22 is a temporary measure to allow for added payment to help offset the costs of the specific handling requirements of the FDA EUA and CDCP guidance. This exception will expire on March 30, 2017 or when a CPT® or Medicare procedure code is issued or when the FDA EUA is rescinded, whichever is sooner 10/01/2016 R4 Change CPT codes in 1) Zika rRT-PCR only – Use CPT® 87798-22 to 87999 and 2) Trioplex rRT-PCR – Use CPT® 87801-22 to 87999 10/01/2016 R3 To add Part A billing information to Narrative: (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form for paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims) 10/01/2016 R2 Revised to add codes to Group 1 10/01/2016 R1 Typographical Error