M01.X11 — Direct infection of right shoulder in infectious and parasitic diseases classified elsewhere
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Claims must include the appropriate CPT® or PLA code and supporting ICD-10-CM diagnosis codes that document medical necessity, with corresponding documentation in the patient record to support the selected ICD-10-CM codes.
- When required, enter the appropriate DEX Z-Code® adjacent to the CPT® code in the specified claim fields (Part B: Loop 2400/SV101-7 for 837P or Item 19 for paper; Part A: SV202-7 for 837I or Block 80 UB04).
- Tests billed with CPT® 87999, or tests submitted for non-standard indications, require submission of a DEX Z-Code® and a MolDX Technical Assessment (TA).
- For expanded (>5 pathogens) RP/PNP/GI panels billed under non-listed POS, the claim must include an appropriate Group 6 or Group 7 ICD-10 diagnosis plus a sign/symptom code from Group 1 or Group 2, or documentation of pre-transplant evaluation for immune-compromised beneficiaries.
Key Coverage Criteria
- Bill molecular syndromic infectious disease panels with the appropriate proprietary CPT® or PLA code and an accompanying ICD-10-CM diagnosis that supports medical necessity.
- FDA-approved or -cleared infectious disease molecular tests performed consistent with their intended use may be billed without a DEX Z-Code® when billed with an appropriate ICD-10-CM diagnosis that documents medical necessity.
- A molecular syndromic panel is reported as a single test with one unit of service (UOS = 1) and is eligible for payment when the panel code and documentation meet policy criteria.
- Expanded (>5 pathogens) respiratory (RP), pneumonia (PNP), and gastrointestinal (GI) panels are billable when performed at POS 19, 21, 22, or 23 OR when ordered by the specified specialists by beneficiary immune status (immune-competent: Infectious Disease or Pulmonologist for RP/PNP or Gastroenterologist for GI; immune-compromised: Infectious Disease, Oncology, Transplant, Pulmonologist for RP/PNP, or Gastroenterologist for GI).
- When organisms are not included in a panel, additional targeted testing for those organisms may be reasonable and necessary if ordered in addition to the panel and supported by documentation in the medical record.
- Molecular syndromic panels for infectious disease pathogen identification are covered when billed with the appropriate proprietary CPT®/PLA code (or acceptable CPT code) and accompanied by supporting ICD-10-CM diagnosis codes documented in the medical record that justify medical necessity.
20 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
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
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