Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (A56642)


Related Local Coverage Determination (LCD)
L38229-Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)


Contractor NameContract NumberStates
Novitas Solutions, Inc. 04111 - A and B MAC Colorado
04112 - A and B MAC Colorado
04211 - A and B MAC New Mexico
04212 - A and B MAC New Mexico
04311 - A and B MAC Oklahoma
04312 - A and B MAC Oklahoma
04411 - A and B MAC Texas
04412 - A and B MAC Texas
04911 - A and B MAC Colorado
New Mexico
Oklahoma
Texas
07101 - A and B MAC Arkansas
07102 - A and B MAC Arkansas
07201 - A and B MAC Louisiana
07202 - A and B MAC Louisiana
07301 - A and B MAC Mississippi
07302 - A and B MAC Mississippi
12101 - A and B MAC Delaware
12102 - A and B MAC Delaware
12201 - A and B MAC District of Columbia
12202 - A and B MAC District of Columbia
12301 - A and B MAC Maryland
12302 - A and B MAC Maryland
12401 - A and B MAC New Jersey
12402 - A and B MAC New Jersey
12501 - A and B MAC Pennsylvania
12502 - A and B MAC Pennsylvania
12901 - A and B MAC Delaware
District of Columbia
Maryland
New Jersey
Pennsylvania

Article Information

Article ID Number: A56642 Status: A-Approved

Article Title: Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)

Original Article Effective Date: 12/30/2019

Revision Effective Date: 12/30/2019

Article Text:

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38229 Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs).  Please refer to the LCD for reasonable and necessary requirements. 

Coding Guidelines

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

A GIP test panel is a single service with a single unit of service (UOS=1). A GIP test panel must not be unbundled and billed as individual components regardless of the fact that the GIP test panel reports multiple individual pathogens and/or targets.

Utilization Parameters

Medicare will allow only one GIP multiplex panel (CPT code 87505, 87506, 87507 or 0097U) per day per beneficiary by the same or different provider consistent with the related LCD.

Repeat NAAT testing within 7 days during the same episode of diarrhea will be denied (any combination of CPT codes 87505, 87506, 87507 or 0097U) when initial test result is negative.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

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.

999Not Applicable

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes:

Group 1 Paragraph:

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.



Group 1 CPT Codes:
0097U GASTROINTESTINAL PATHOGEN, MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, MULTIPLE TYPES OR SUBTYPES, 22 TARGETS (CAMPYLOBACTER [C. JEJUNI/C. COLI/C. UPSALIENSIS], CLOSTRIDIUM DIFFICILE [C. DIFFICILE] TOXIN A/B, PLESIOMONAS SHIGELLOIDES, SALMONELLA, VIBRIO [V. PARAHAEMOLYTICUS/V. VULNIFICUS/V. CHOLERAE], INCLUDING SPECIFIC IDENTIFICATION OF VIBRIO CHOLERAE, YERSINIA ENTEROCOLITICA, ENTEROAGGREGATIVE ESCHERICHIA COLI [EAEC], ENTEROPATHOGENIC ESCHERICHIA COLI [EPEC], ENTEROTOXIGENIC ESCHERICHIA COLI [ETEC] LT/ST, SHIGA-LIKE TOXIN-PRODUCING ESCHERICHIA COLI [STEC] STX1/STX2 [INCLUDING SPECIFIC IDENTIFICATION OF THE E. COLI O157 SEROGROUP WITHIN STEC], SHIGELLA/ENTEROINVASIVE SCHERICHIA COLI [EIEC], CRYPTOSPORIDIUM, CYCLOSPORA CAYETANENSIS, ENTAMOEBA HISTOLYTICA, GIARDIA LAMBLIA [ALSO KNOWN AS G. INTESTINALIS AND G. DUODENALIS], ADENOVIRUS F 40/41, ASTROVIRUS, NOROVIRUS GI/GII, ROTAVIRUS A, SAPOVIRUS [GENOGROUPS I, II, IV, AND V])
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
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


ICD-10 Codes That Are Covered

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM code supports medical necessity and provides coverage for CPT codes: 87505, 87506, 87507 and 0097U.

R19.7 Diarrhea, unspecified

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 87505, 87506, 87507 and 0097U when used for patients with a paralytic ileus as outlined per the related LCD.

K56.0 Paralytic ileus
R10.84 Generalized abdominal pain
R11.2 Nausea with vomiting, unspecified
ICD-10 Codes That Are Not Covered

XX000


Revision History Information
Revision History DateRevision History NumberRevision History Explanation
12/30/2019
R2

Article revised and published on 8/13/2020 effective for dates of service on and after 12/30/2019 in response to an external request. CPT Code Group 2 has been combined with CPT Code Group 1 and the ICD-10 Code Group 2 Paragraph and Codes were removed. The prior ICD-10 Code Group 3 is now Group 2. In addition, the paragraph related to the NCCI edits and manual has been removed and minor formatting changes have been made.

12/30/2019
R1

Future billing and coding Article related to L38229, Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) published on November 14, 2019 and will become effective on December 30, 2019.