Effective as of June 2, 2022, LCD L38988 pertaining to molecular syndromic panels for infectious disease pathogen identification testing went into effect.
Currently, Palmetto GBA is one of the main Medicare MACs requiring this information; however, it appears some advantage plans are also using this LCD and possibly BlueCross BlueShield, Humana and other private insurance plans are also adopting.
This new rule applies to newer molecular panels, including UTI, STI, Respiratory, Women’s Health, Flu, and Gastrointestinal. Previously, these were ordered and billed as separate tests and could net acceptable reimbursement as there are multiple tests in any of these panels.
Palmetto introduced an LCD stating “lab developed panels” of 5 or more pathogens for PCR based UTI testing needs to be set up as a single panel code and approved by Palmetto prior to submitting. The tests are all standard molecular tests, but each lab may have their own version of this panel based on the tests they prefer. Instead of billing multiple components, the panels will have the 87999 CPT and then the Z code specific to that labs panel. Many labs have done the work to define and apply for the Z code.
Once the Z code is approved, it then must go through the technical assessment. Palmetto uses this to determine if the panel is necessary for effective treatment of patients. There can be challenges to passing the technical assessment and should a lab fail this step they will not receive reimbursement on their UTI test.
With the possible challenge of passing the technical assessment and the delay in any change, labs are forced to file claims knowing they will be denied with hopes to appeal the claim at a later date or hold the claims until they receive further guidance from Palmetto.
Visit the CMS website for more information on L38988 MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing or the Palmetto GBA website to review frequently asked questions for molecular syndromic panels for infectious disease pathogen identification testing.