About this policy
Jurisdiction: JK MAC Part B. States: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont. Type: Active LCD
Coverage indications
Indications and Limitations of Coverage* One † multiplex GPP^ is covered when at least ONE of the following applies: Community-acquired acute diarrhea (≥3 loose or watery stools/day for ≤14 days) with at least ONE of the following (1-3): >1 week duration Severe illness (e.g., profuse watery diarrhea, signs of hypovolemia, passage of ≥6 unformed stools per 24 hours, severe abdominal pain, need for hospitalization) Inflammatory diarrhea (bloody diarrhea, small volume mucous stools, fever) High-risk host (e.g., age ≥70 years, cardiac disease, immunocompromising condition, inflammatory bowel disease, pregnancy) Public health concerns (e.g., food handler, health care or day care worker) Pre-transplant evaluation (4) Contraindications to Coverage (ANY) As a test of cure (3,5) More than 72 hr. after hospitalization while still an inpatient (1,6-8) Laxatives in the prior 48 hours (7, 32), excluding those with signs of severe disease *See associated Billing & Coding article for specific diagnosis codes, POS, and credentialing requirements. † A second panel test for the same clinical indication is covered if the first panel yielded a negative result AND there is a high index of suspicion for a pathogen as the cause of symptoms, AND the patient’s clinical condition is not improving or is deteriorating, AND as long as the test fulfills the criteria for coverage set forth in the LCD. ^Tests must be FDA approved/cleared, or if a laboratory developed test (LDT), have a published, peer-reviewed study supporting analytic validity, or certification by a third-party consistent with the New York State Department of Health’s Clinical Laboratory Evaluation Program (CLEP) review standards.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 87505 | CPT | Covered |
| 87506 | CPT | Covered |
| 87507 | CPT | Covered |
| A00.0 | ICD10CM | Covered |
| A00.1 | ICD10CM | Covered |
| A00.9 | ICD10CM | Covered |
| A01.00 | ICD10CM | Covered |
| A01.1 | ICD10CM | Covered |
| A01.2 | ICD10CM | Covered |
| A01.3 | ICD10CM | Covered |
| A02.0 | ICD10CM | Covered |
| A03.0 | ICD10CM | Covered |