A04.8 — Other specified bacterial intestinal infections
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All services ordered or rendered must be signed and dated in the medical record, including a signed and dated office visit record or operative report.
- An Advance Beneficiary Notice (ABN), Form CMS-R-131, should be signed by the beneficiary when applicable to indicate acceptance of financial responsibility.
- The patient's medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.
- The medical record must document relevant medical history and the results of pertinent tests or procedures.
Key Coverage Criteria
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
- A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
- 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.
17 Active Policies
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A58963 — Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)
J06
L39226 — Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)
J06
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