Knowledge Base Article

News related to the Zika virus has slipped from the headlines as the United States deals with a major hurricane and the upcoming presidential election, but the Zika virus hasn’t gone away. According to the Center for Disease Control and Prevention (CDC), as of October 5, 2016, there were 3,818 cases of Zika Virus disease cases in the United States with most of these cases being travel-associated. However, 105 cases in South Florida (Miami and Miami Beach area) are locally acquired mosquito-borne cases. Zika infection during pregnancy can cause serious birth defects and other pregnancy problems, and a small proportion of people with recent Zika virus infection may develop Guillain-Barre syndrome. You can learn more about the Zika virus on the CDC Zika Virus website.

In order to properly treat Zika virus infection, a diagnosis must first be established. According to Medicare MLN Matters Article SE1615, “Currently there are a few diagnostic tests that can determine the presence of the virus. These tests are available through the CDC and CDC-approved state health laboratories. A small number of tests have been issued an Emergency Use Authorization by the Food and Drug Administration (FDA) and may be available through commercial laboratories.”

Medicare Part B will pay for testing for the Zika virus that is reasonable and necessary for diagnosis or treatment. Since there are currently no specific HCPCS codes for Zika virus testing, Article SE1615 directs laboratories to obtain guidance on appropriate billing codes from their local Medicare Administrative Contractors (MACs). The MACs may require resource and costs information from the testing labs in order to establish appropriate payment rates.

In reviewing the websites of the different MACs and the Medicare Coverage Database, I was able to locate the following MAC specific instructions for billing for Zika virus testing.

NGS - http://tinyurl.com/hpp7zhe

“Testing for the Zika virus may be considered medically necessary when a beneficiary’s clinical history and symptoms indicate the possibility of infection with the virus. Coverage for this testing is not available on a screening basis, but only for situations in which there is valid medical reason to suspect Zika infection.

Providers billing for Zika viral testing may submit claims using the following codes:

• CPT Code 87798 (infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism)
• ICD-10 Code A92.9 (through 9/30/2016)
• ICD-10 Code A92.5 (10/1/2016 and thereafter)”

Noridian - http://tinyurl.com/zc4kxu7

Noridian has issued Coverage Articles (see the one for Noridian JE at the link above) for Zika Virus Testing by PCR and ELISA Methods (A55326 and A55327). These articles list several billing codes that may be appropriate based on the type of test performed.

Novitas – http://tinyurl.com/zuxqf3v

“Presently, there are no specific HCPCS (Healthcare Common Procedure Coding System) codes for testing of the Zika virus; however, Novitas recommends that laboratories refer to coding resources such as the HCPCS and Current Procedural Terminology manuals to select the most appropriate unlisted code. Please keep in mind that medical documentation must support the services billed. To establish appropriate payment amounts for the tests, laboratories should provide resources and cost information upon request.”

Palmetto - http://tinyurl.com/hslt92h

“To bill for Zika virus testing, submit the claims with CPT 87999. Please keep in mind that medical documentation must support the services billed. Clinical laboratories may be asked by Medicare administrative contractors to provide resources and cost information to establish appropriate payment amounts for the tests.”

If your MAC is not listed above, you should contact them for billing information.