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 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: 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 Group 2 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. Group 2 CPT Codes: 0369U INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA AND RNA), GASTROINTESTINAL PATHOGENS, 31 BACTERIAL, VIRAL, AND PARASITIC ORGANISMS AND IDENTIFICATION OF 21 ASSOCIATED ANTIBIOTIC-RESISTANCE GENES, MULTIPLEX AMPLIFIED PROBE TECHNIQUE 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 and 87506. 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 code supports medical necessity and provides coverage for CPT codes: 0369U and 87507. 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. Note: None of the diagnosis codes listed in Table 3 are stand-alone diagnosis codes. Group 3 (Immunosuppression diagnosis codes – secondary codes to be reported with those in Group 2) B20 Human immunodeficiency virus [HIV] disease D80.0 Hereditary hypogammaglobulinemia D80.1 Nonfamilial hypogammaglobulinemia D80.2 Selective deficiency of immunoglobulin A [IgA] D80.3 Selective deficiency of immunoglobulin G [IgG] subclasses D80.4 Selective deficiency of immunoglobulin M [IgM] D80.5 Immunodeficiency with increased immunoglobulin M [IgM] D80.6 Antibody deficiency with near-normal immunoglobulins or with hyperimmunoglobulinemia D80.8 Other immunodeficiencies with predominantly antibody defects D81.0 Severe combined immunodeficiency [SCID] with reticular dysgenesis D81.1 Severe combined immunodeficiency [SCID] with low T- and B-cell numbers D81.2 Severe combined immunodeficiency [SCID] with low or normal B-cell numbers D81.31 Severe combined immunodeficiency due to adenosine deaminase deficiency D81.4 Nezelof's syndrome D81.5 Purine nucleoside phosphorylase [PNP] deficiency D81.6 Major histocompatibility complex class I deficiency D81.7 Major histocompatibility complex class II deficiency D81.810 Biotinidase deficiency D81.818 Other biotin-dependent carboxylase deficiency D81.89 Other combined immunodeficiencies D82.0 Wiskott-Aldrich syndrome D82.1 Di George's syndrome D82.2 Immunodeficiency with short-limbed stature D82.3 Immunodeficiency following hereditary defective response to Epstein-Barr virus D82.4 Hyperimmunoglobulin E [IgE] syndrome D82.8 Immunodeficiency associated with other specified major defects D83.0 Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function D83.1 Common variable immunodeficiency with predominant immunoregulatory T-cell disorders D83.2 Common variable immunodeficiency with autoantibodies to B- or T-cells D83.8 Other common variable immunodeficiencies D84.0 Lymphocyte function antigen-1 [LFA-1] defect D84.1 Defects in the complement system D84.81 Immunodeficiency due to conditions classified elsewhere D84.821 Immunodeficiency due to drugs D84.822 Immunodeficiency due to external causes D84.89 Other immunodeficiencies 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 D89.49 Other mast cell activation disorder D89.810 Acute graft-versus-host disease D89.811 Chronic graft-versus-host disease D89.812 Acute on chronic graft-versus-host disease D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere classified 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 ICD-10 Codes That Are Not Covered XX000

Revision History Information

Revision History Date Revision History Number Revision History Explanation 04/01/2023 R5 Article revised and published on 04/20/2023 effective for dates of service on and after 04/01/2023 to reflect the April Quarterly CPT/HCPCS Code Update. CPT code ‘0369U’ was added to the 'Article Text/Utilization Parameters', ‘CPT/HCPCS Codes Group 2’ and ‘ICD-10-CM Codes that Support Medical Necessity/Group 2 Paragraph’. 10/16/2022 R4 Article effective for dates of service on and after 10/16/2022. Draft article posted 04/14/2022. 04/01/2022 R3 Article revised and published on 05/05/2022 effective for dates of service on and after 04/01/2022 to reflect the April Quarterly CPT/HCPCS Code Update. The following HCPCS code was removed from the 'Utilization Parameters', the ‘Group 1 Codes’ and the ‘ICD-10-CM Codes that Support Medical Necessity/Group 1 and Group 2 Paragraph' sections: 0097U. The ‘ICD-10-CM Codes that Support Medical Necessity’ section for the ‘Group 2 Codes’ and the associated asterisk note were revised for clarification. 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.