0115U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For Part A UB04 paper claim forms, enter the DEX Z-Code adjacent to the CPT code in Block 80.
- For Part B electronic 5010A1 837P claims, enter the DEX Z-Code adjacent to the CPT code in Loop 2400 or SV101-7.
- For Part B paper claims, enter the DEX Z-Code adjacent to the CPT code in Box 19 of the paper claim form.
- For Part A electronic 837I claims, enter the DEX Z-Code adjacent to the CPT code on line SV202-7.
Key Coverage Criteria
- To report a Molecular Diagnostic Test (MDT) service, submit the appropriate CPT code, include the appropriate DEX Z-Code identifier adjacent to the CPT code in the claim comment/narrative field, and enter 1 unit of service (UOS).
- Molecular syndromic panels for infectious disease pathogen identification are covered when billed with the appropriate proprietary CPT®/PLA code (or acceptable CPT code) and accompanied by supporting ICD-10-CM diagnosis codes documented in the medical record that justify medical necessity.
- FDA-cleared/approved molecular infectious disease tests performed consistent with their FDA intended-use labeling are billable without a DEX Z-Code when accompanied by an appropriate ICD-10-CM code and documentation of medical necessity.
- Expanded (>5 pathogen) respiratory (RP), pneumonia (PNP), and gastrointestinal (GI) panels may be billed when either (a) the place of service is 19, 21, 22, or 23, or (b) the ordering provider is an appropriate specialist per immune-status and panel type and the claim includes the required ICD-10 codes (Group 6/7 plus signs/symptoms from Groups 1/2), with pre-transplant immune-compromised testing allowed regardless of symptoms with supporting documentation.
- Additional panel testing for content that is non-duplicative of an existing panel on the same date of service can be billed for the non-duplicative content if the medical record documents the non-duplication and all other policy criteria are met.
- Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT® or PLA code and an accompanying ICD-10-CM diagnosis that documents medical necessity in the patient record.
20 Active Policies
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.