0556U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Enter 1 unit of service (UOS) for the Molecular Diagnostic Test on the claim.
- Report the appropriate CPT code for the Molecular Diagnostic Test on the claim.
- For Part B electronic (837P) claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in Loop 2400 or the SV101-7 comment/narrative field.
- For Part B paper claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in Box 19.
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).
- Hospitalized patients with suspected influenza should receive influenza testing using molecular methods (e.g., RT-PCR).
- Use rapid diagnostic influenza tests only if they have high sensitivity and specificity per CDC recommendations and manufacturer performance claims.
- Collect respiratory tract specimens for influenza testing as early in the illness as possible, ideally within 3-4 days of symptom onset.
- Consider RT-PCR (or other targeted molecular methods) to confirm RIDT results when community influenza activity is low and an RIDT is positive.
- Consider RT-PCR to confirm RIDT results when community influenza activity is high and an RIDT is negative.
15 Active Policies
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
A57526 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
A57527 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
A59055 — Billing and Coding: Influenza Diagnostic Tests
Related Codes
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