Billing and Coding: Zika Virus Testing by PCR and ELISA Methods

For calendar year 2018 CMS has adopted the new 2018 AMA CPT codes for Zika
virus testing. For dates of service 1/1/2018 and forward providers should bill
using these new codes. For dates of service prior to 1/1/2018 the previous
instructions will still apply.

Testing for the Zika virus must follow the Food and Drug Administration (FDA)
and CDCP guidelines. This article does not address medical necessity but
rather proper coding for claims submission.

Claims submissions should utilize the coding instructions below regardless of
the specimen source. In the narrative section of the claim form (Part A Loop
2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form or paper
claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500
form for paper claims) please enter the following verbiage (without quotation
marks) as it pertains to the respective tests.

For Claims submitted prior to 1/1/2018 use the following guidance:

  1. Zika rRT-PCR only - Use CPT 87999 and enter "Zika PCR" in the narrative field regardless of the CDCP approved proprietary test utilized*
  2. Trioplex rRT-PCR - Use CPT 87999 and enter "Zika Trioplex"*
  3.  anti-Zika immunoglobulin (IgM) - Use CPT 86790 
  4. Dengue rRT-PCR only - use CPT 87798 
  5. Chikungunya rRT-PCR only - use CPT 87798
  6. If billing for both Dengue and Chikungunya rRT-PCR - use CPT 87801 once.

If a plaque reduction neutralization test (PRNT) is indicated, that testing
must be conducted by CDC or by a PRNT laboratory designated by CDC to do
confirmatory PRNT testing for the Zika response. The claim for PRNT testing is
not submitted to Medicare.  
  
Items 1, 2 and 3 above require an FDA Emergency Use Authorization to the
respective laboratory. Noridian retains the right to be sent a copy of the
respective lab's EUA upon request.

For claims submitted with dates of service on or after 1/1/2018 use the
following instructions:

  1. Zika rRT-PCR only - Use CPT 87662
  2. Zika virus IgM - Use CPT 86794
  3. Dengue rRT-PCR only - use CPT 87798
  4. Chikungunya rRT-PCR only - use CPT 87798
  5. If billing for both Dengue and Chikungunya rRT-PCR - use CPT 87801 once.

Diagnosis coding should include at least one of the following ICD-10 codes:

Code | Description  
---|---  
A92.5 | Zika virus disease [effective for DOS on or after October 1, 2016]  
B30.9 | Viral conjunctivitis, unspecified  
M25.50-M25.579 | Pain in joint  
O09.00-O09.93 | Supervision of high risk pregnancy  
O28.3 | Abnormal ultrasonic finding antenatal screening of mother  
O28.4 | Abnormal radiological finding on antenatal screening of mother (MRI
fetus)  
O35.00X1-O35.09X9 | Maternal care for (suspected) central nervous system
malformation or damage in fetus  
R21 | Rash and other nonspecific skin eruption  
R50.9 | Fever, unspecified  
Z03.73 | Encounter for suspected fetal anomaly ruled out  
Z03.79 | Encounter for other suspected maternal and fetal conditions ruled
out.  
Z03.89 | Encounter for observation for other suspected diseases and conditions
ruled out.  
Z33.1 | Pregnant state, incidental  
Z34.00-Z34.93 | Encounter for supervision of normal pregnancy.  
Z36.89 | Encounter for other specified antenatal screening