J02.9 — Acute pharyngitis, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification (e.g., complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- 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.
- Respiratory pathogen panel testing is covered when performed in an outpatient Medicare Part B setting using a single biologic specimen collected and tested on a single date of service, and the results are timely and can affect clinical management to improve patient health outcomes.
- A panel is defined as all respiratory pathogens tested on that single specimen/date and is covered when ordered as a panel (not as a reflex test).
10 Active Policies
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0667 — Esophageal and Airway pH Monitoring
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
ANTHEM-CG-LAB-30 — CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing
A58575 — Billing and Coding: Respiratory Pathogen Panel Testing
Related Codes
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