87636
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Report the appropriate CPT code for the Molecular Diagnostic Test service on the claim.
- Enter 1 unit of service (UOS) for the Molecular Diagnostic Test service on the claim.
- For Part B claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Loop 2400 or SV101-7 for 837P electronic claims and Item 19 for paper claims.
- For Part A claims, enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field: Line SV202-7 for 837I electronic claims and Block 80 for the UB04 claim form.
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).
- Respiratory pathogen panel testing is covered when performed in an outpatient, non-institutional Part B setting from a single biologic specimen on a single date of service and the order is not a reflex test.
- Respiratory pathogen panel testing is covered when the medical record documents that the testing facility can deliver timely results and that the test results can reasonably be expected to change clinical management and improve patient health outcomes.
- Respiratory pathogen panel testing is covered when performed as a single service from a single biologic specimen in the outpatient setting on a single date of service and is reasonable and necessary per LCD L38918.
- The test is covered when performed in a Medicare Part B setting that is equipped to deliver timely results and when the results can reasonably be expected to lead to a change in clinical management that improves health outcomes.
- Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT®/PLA code (or CPT® 87999 if no specific code exists) and accompanied by ICD-10-CM diagnosis codes that support medical necessity documented in the patient record.
20 Active Policies
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A57772 — Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)
J05
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
L36807 — MolDX: Molecular Diagnostic Tests (MDT)
J05
Related Codes
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