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Medicare Coverage for Zika Virus Testing

In February, 2016 the Zika virus was declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO). In the United States, the Centers for Disease Control and Prevention (CDC) considers the Zika virus disease to be a nationally notifiable condition.

The Zika virus is primarily spread through the bite of an infected Aedes species mosquito, although other modes of transmission (including mother-to-child, blood and sexual transmission) have been documented.

Currently, there are a few diagnostic tests that can determine the presence of the virus, and these are available through the CDC and certain CDC-approved health laboratories. In addition, a small number of tests have been released on an emergency basis to commercial laboratories.

Coverage is available through Medicare Part B for clinical diagnostic laboratory tests that are reasonable and necessary for the diagnosis or treatment of a person’s illness or injury. This means that 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)

Related Content

SE1615: Medicare Coverage of Diagnostic Testing for Zika Virus

Medicare Coverage for Zika Virus Testing
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