Palmetto Final LCD Denies Coverage to Large Respiratory Panels
October 5, 2018Palmetto GBA finalized local coverage determinations for viral respiratory panels yesterday, determining that the use of small multiplex viral panels in susceptible populations may be reasonable and necessary, but the use of highly multiplexed nucleic acid amplification tests as front-line diagnostics cannot currently be justified.
The measure had been expected after a draft LCD was issued in May 2017 and will now become effective Nov. 12, 2018.
Multiplex respiratory viral assays are assigned billing codes that relate to the number of targets in the test. Tests with three to five targets are coded by CPT code 87631, while CPT codes 87632 and 87633 relate to tests with six to 11, and 12 to 25 targets, respectively.
In the finalized Palmetto LCD, tests that fall under the three- to five-target 87631 code will be covered under limited circumstances. They will be covered related to the place of service – urgent care, inpatient hospital, or emergency room – when ordered by any provider qualified to order tests. But they must be ordered by an infectious disease specialist in order to be covered outside of one of these places of service, provided that an ID specialist is reasonably available.
More highly multiplexed tests that fall under the CPT codes 87632 and 87633 will be not be covered.