87641
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
- A claim submitted without a valid ICD-10-CM diagnosis code will be returned as an incomplete claim under Section 1833(e) of the Social Security Act; diagnosis must best describe the patient's condition for which the service was performed.
- For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.
- For diagnostic (non-screening) use of the test, report the test result if known; if result is not available, report the symptoms prompting the test.
- When billing CPT 87641 for screening purposes (statutorily non-covered), ICD-10-CM diagnosis codes may be reported but payment will still be denied.
Key Coverage Criteria
- 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.
- FDA-approved or cleared molecular infectious disease tests performed consistent with their intended use labeling are covered without a DEX Z-Code and Technical Assessment when billed with appropriate ICD-10-CM diagnosis codes and supporting documentation.
- Expanded (>5 pathogens) respiratory (RP/PNP) and gastrointestinal (GI) panels are covered if billed from place of service (POS) 19, 21, 22, or 23, or if ordered by an appropriate specialist depending on beneficiary immune status and the specialist is diagnosing/treating the beneficiary.
- For immune-compromised beneficiaries, expanded panels (RP/PNP/GI/other panels) are covered when ordered by a specialist in Infectious Diseases, Oncology, Transplant, Pulmonology (for RP/PNP), or Gastroenterology (for GI) who is diagnosing and treating the beneficiary.
- Pre-transplant evaluation testing for an immune-compromised beneficiary is covered regardless of symptoms when clear documentation of the pre-transplant evaluation accompanies the claim.
- Additional testing for organisms not included in a panel may be reasonable and covered when ordered in addition to the panel and supported by documentation in the medical record demonstrating non-duplication and medical necessity.
11 Active Policies
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A52379 — Billing and Coding: CPT Code 87641 (Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique)
J06
A58726 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
Related Codes
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