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Claims & Payment Policy: Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing - KY Medicaid

April 4, 2022

WellCare is implementing the following policy for Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing effective May 7, 2022.

Summary of Policy:

WellCare will be limiting payment for GI pathogen panels of 12+ targets (CPT 87507 and 0097U) to inpatient settings, including inpatient hospital (POS 21), emergency department (POS 23), and outpatient hospital (POS 22).

CPT® Codes

Description

87507

Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets

0097U

Gastrointestinal pathogen, multiplex reverse transcription and multiplex amplified probe technique, multiple types or subtypes, 22 targets (Campylobacter [C. jejuni/C. coli/C. upsaliensis], Clostridium difficile [C. difficile] toxin A/B, Plesiomonas shigelloides, Salmonella, Vibrio [V. parahaemolyticus/V. vulnificus/V. cholerae], including specific identification of Vibrio cholerae, Yersinia enterocolitica, Enteroaggregative Escherichia coli [EAEC], Enteropathogenic Escherichia coli [EPEC], Enterotoxigenic Escherichia coli [ETEC] lt/st, Shiga-like toxin-producing Escherichia coli [STEC] stx1/stx2 [including specific identification of the E. coli O157 serogroup within STEC], Shigella/Enteroinvasive Escherichia coli [EIEC], Cryptosporidium, Cyclospora cayetanensis, Entamoeba histolytica, Giardia lamblia [also known as G. intestinalis and G. duodenalis], adenovirus F 40/41, astrovirus, norovirus GI/GII, rotavirus A, sapovirus [Genogroups I, II, IV, and V])

What does this mean for providers?

WellCare will deny payment for CPT code 87507 and HCPCS code 0097U when billed outside of the following places of service: inpatient hospital (21), outpatient hospital/observation (22), and ED (23). Note: these large panels are appropriate for diagnostic information for members in critical care or who are immune compromised.

If a provider does not agree with WellCare’s decision, they may dispute or appeal the denial. WellCare will require medical records that substantiate provider billing.

Providers can review the complete policy on our Payment Policies page.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.

Sincerely, 

WellCare Health Plans