ED Coding and Reimbursement Alert

Documentation must show why the Zika testing was necessary.

Testing for Zika virus is now covered under Part B - provided you meet a few CMS requirements.

In a special edition article of MLN Matters, Number: SE1615 Related Change Request, CMS announced that Zika virus testing is covered under Medicare Part B as long as the clinical diagnostic laboratory test is reasonable and necessary for the diagnosis or treatment of a person's illness or injury.

According to the Centers for Disease Control and Prevention (CDC), the Zika virus disease is a nationally notifiable condition that has caused outbreaks in many countries and territories. The virus is primarily spread through the bite of an infected Aedes species mosquito. Other modes of transmission include mother-to-child transmission, blood transfusion and sexual transmission.

Currently there are a few diagnostic tests that can determine the presence of the virus that are available through the CDC and CDC-approved state health laboratories.

Prove Zika Testing Is Reasonable and Necessary

Medicare Part B pays for clinical diagnostic laboratory tests that are reasonable and necessary for the diagnosis or treatment of a person's illness or injury. Presently there are no specific HCPCS codes for testing of the Zika virus; however, laboratories should contact their local MACs for guidance on the appropriate billing codes to use on claims for Zika virus testing. Laboratories should also provide resources and cost information that will allow the MACs to establish appropriate payment amounts for the tests.

Take Home Point: Although the labs are likely doing the actual billing for the diagnostic testing, emergency physicians and their coders need to provide the diagnosis codes to justify the medical necessity of the test, says, Sarah Todt, RN, CPMA, CPC, CEDC, Director or Provider Education & Audit for LogixHealth, a national coding and billing company in, Bedford, MA.

Code the Symptoms That Make You Suspect Zika Virus

Since it is the diagnostic lab test that confirms the Zika diagnosis, patients with Zika viral illnesses may present with symptoms other than fever such as: maculopapular rash, arthralgia, conjunctivitis, headache and myalgia. Report the symptoms when the disease is not confirmed, Todt explains.

Reminder: There is no specified ICD-10-CM code for Zika virus and until October 2016, so in the meantime coders can use A92.8 (Other specified mosquito-borne viral fevers) when appropriate. With the implementation of the new ICD-10 codes in the October 2016 ICD-10-CM update, you should report A92.5 (Zika virus disease) once the diagnosis is confirmed, Todt warns.