O35.09X4 — Maternal care for (suspected) other central nervous system malformation or damage in fetus, fetus 4
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Enter specific test verbiage in the claim narrative field: for pre-1/1/2018 Zika rRT-PCR enter 'Zika PCR'; for pre-1/1/2018 Trioplex enter 'Zika Trioplex'; for other tests enter test-appropriate verbiage, using Part A Loop 2300/NTE or Form Locator 80 (CMS 1450) or Part B Loop 2400/SV101-7 or Item 19 (CMS 1500) as applicable.
- Claims must include at least one of the specified ICD-10 diagnosis codes on the claim to support Zika-related test billing.
- Laboratories must have and make available their FDA Emergency Use Authorization (EUA) for the respective test upon Noridian request.
- PRNT confirmatory testing, if indicated, is performed by CDC or CDC-designated labs and the PRNT test result/process is not billed to Medicare (do not submit PRNT claims).
Key Coverage Criteria
- For dates of service on or after 1/1/2018, bill Zika rRT-PCR using CPT 87662 when testing is ordered and the claim includes at least one of the listed ICD-10 diagnosis codes and testing follows FDA and CDC guidelines.
- For dates of service prior to 1/1/2018, bill Zika rRT-PCR using CPT 87999 and enter 'Zika PCR' in the claim narrative field when testing is ordered and the claim includes at least one of the listed ICD-10 diagnosis codes.
- For dates of service on or after 1/1/2018, bill Zika virus IgM testing using CPT 86794 when testing is ordered and the claim includes at least one of the listed ICD-10 diagnosis codes.
- Bill Dengue rRT-PCR using CPT 87798 when Dengue testing is ordered and the claim includes at least one of the listed ICD-10 diagnosis codes.
- Bill Chikungunya rRT-PCR using CPT 87798 when Chikungunya testing is ordered and the claim includes at least one of the listed ICD-10 diagnosis codes.
- If both Dengue and Chikungunya rRT-PCR testing are performed on the same date of service, bill once using CPT 87801.
2 Active Policies
A55327 — Billing and Coding: Zika Virus Testing by PCR and ELISA Methods
A55326 — Billing and Coding: Zika Virus Testing by PCR and ELISA Methods
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.