ModifiedWellCarePolicy CG.CP.MP.04

Coding Implications — Syndromic Multiplex GI Pathogen Panels and H. pylori Testing (Outpatient)

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Defines medical necessity criteria and coding for outpatient syndromic multiplex GI pathogen panels and Helicobacter pylori noninvasive tests; affects ordering providers, laboratories, and claims reviewers for WellCare members.

Policy Summary

PayerWellCare

PolicyCoding Implications — Syndromic Multiplex GI Pathogen Panels and H. pylori Testing (Outpatient)

Policy CodePolicy CG.CP.MP.04

Change TypeCoding table addedCPT description corrections

Effective Date

Next Review Date

Key ActionOrder syndromic multiplex GI panels or H. pylori tests only when outpatient clinical criteria are met and document supporting clinical indications.

SourceLink

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ModifiedWellCarePolicy CG.CP.MP.04

Coding Implications — Syndromic Multiplex GI Pathogen Panels and H. pylori Testing (Outpatient)

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Policy Summary

PayerWellCare

PolicyCoding Implications — Syndromic Multiplex GI Pathogen Panels and H. pylori Testing (Outpatient)

Policy CodePolicy CG.CP.MP.04

Change TypeCoding table addedCPT description corrections

Effective Date

Next Review Date

Key ActionOrder syndromic multiplex GI panels or H. pylori tests only when outpatient clinical criteria are met and document supporting clinical indications.

SourceLink

POLICY UPDATE CHANGES

Added CPT code table and moved the 'coding implications' section.

Corrected coding descriptions in CPT table and removed code 0369U; corrected policy number to CG.CP.MP.04.

Added 'lab' to title and removed CPT and ICD-10 codes from the policy reference table.

Corrected coding descriptions in CPT table; removed 0369U.

11 or fewertargets for one syndromic multiplex GI panel group

12 or moretargets for broader syndromic multiplex GI panel group

once/14dtesting frequency limit per incident for multiplex GI panels

30+CPT codes provided in coding table

policy # fixedadministrative correction

Coverage and Medical Necessity Criteria

Syndromic Multiplex Gastrointestinal Pathogen Panels with 11 or Fewer Targets

Syndromic/Multiplex Gastrointestinal Pathogen Panels with 11 or Fewer Targets may be considered medically necessary when ALL of the following are met:

ALL of the following

The member/enrollee presents in the outpatient setting with suspected infectious gastroenteritis.
AND at least one of the following:
- Immunocompromised status (e.g., HIV/AIDS, immunosuppression therapy, primary immunodeficiency)
- Recent travel to or contact with travelers from an infectious diarrheal disease–endemic area
- Dysentery (presence of blood or mucus in stool)
- Fever
- Dehydration
- Abdominal pain or tenderness
- Bacteremia
- Diarrhea persisting longer than 7 days
- Symptoms of enteric fever (e.g., typhoid/paratyphoid fever)
Results of the testing will influence the member's/enrollee's clinical management.

Frequency

Frequency — Use frequency rule:

ALL of the following

Syndromic/Multiplex Gastrointestinal Pathogen Panels with 11 or fewer targets: medically necessary once per incident of diarrheal disease, or no more than once per 14-day period.

Syndromic Multiplex Gastrointestinal Pathogen Panels with 12 or More Targets

Syndromic/Multiplex Gastrointestinal Pathogen Panels with 12 or More Targets may be considered medically necessary when ALL of the following are met:

ALL of the following

The member/enrollee presents in the outpatient setting with suspected infectious gastroenteritis.
AND at least one of the following:
- Immunocompromised status (e.g., HIV/AIDS, immunosuppression therapy, primary immunodeficiency)
- Recent travel to or contact with travelers from an infectious diarrheal disease–endemic area
- Bacteremia

Frequency

Frequency — Use frequency rule:

ALL of the following

Syndromic/Multiplex Gastrointestinal Pathogen Panels with 12 or more targets: medically necessary once per incident of diarrheal disease, or no more than once per 14-day period.

Helicobacter pylori (H. pylori) Urea Breath or Stool Antigen Tests

H. pylori Urea Breath or Stool Antigen Tests may be considered medically necessary when ANY ONE of the following applies:

ANY of the following

Active peptic ulcer disease (PUD).
Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.
History of endoscopic resection of early gastric cancer (EGC).
Past history of PUD:
- Previous cure of H. pylori infection has NOT been documented.
Dyspepsia (uninvestigated):

Coding and Panel Target Counts

Referenced CPT CodesCPT

83013	Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13).
83014	Helicobacter pylori; drug administration.
86677	Antibody; Helicobacter pylori.
87338	Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; Helicobacter pylori, stool.
87339	Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; Helicobacter pylori.
87493	Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique.
87498	Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed.
87500	Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique.
87505	Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
87506	Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.

1–10 of 22

1/3

CPT codes in Coding ImplicationsCPTCovered

87652	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification.
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique.
87797	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism.
87798	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.
87799	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism.
87800	Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique.
87801	Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique.

inv-12: Panel target counts — 11 or fewer targets vs. 12 or more targets

Panel target threshold (smaller panel)11 or fewer targets

Panel target threshold (larger panel)12 or more targets

Clinical distinction11-or-fewer panels: broader list of outpatient clinical indications (includes dysentery, fever, dehydration, abdominal pain/tenderness, diarrhea >7 days)

Clinical distinction12-or-more panels: more restricted indications required (eg, immunocompromised status, travel exposure, bacteremia, or symptoms of enteric fever)

Frequency limitTesting is medically necessary once per incident of diarrheal disease or no more than once per 14-day period

Provider Responsibilities, Documentation, and Billing

Prior Authorization

Prior Authorization Required / Frequency Limits

Prior Authorization and frequency: Syndromic multiplex gastrointestinal (GI) pathogen panels require documentation that testing is medically necessary. Multiplex GI panels (both ≤11 targets and ≥12 targets) are medically necessary only when the patient presents in the outpatient setting with suspected infectious gastroenteritis and meets at least one listed high-risk or clinical criteria (e.g., immunocompromised status, recent travel to endemic area, dysentery, fever, dehydration, abdominal pain/tenderness, bacteremia, diarrhea >7 days, or symptoms of enteric fever). Results must be expected to influence clinical management. Frequency is limited to once per incident of diarrheal disease, or no more than once per 14-day period.

Prior authorization/frequency: Panels are limited to once per diarrheal incident or ≤14 days between tests.
Required clinical context: Outpatient presentation with suspected infectious gastroenteritis AND at least one listed criterion (see policy clinical criteria).
Medical necessity: Results must influence clinical management or testing may be denied.

Background and Clinical Context

Acute diarrheal infections are common and attributable to bacteria, viruses, fungi, and parasites. Molecular multiplex testing can detect multiple gastrointestinal pathogens simultaneously and is increasingly used to evaluate suspected infectious gastroenteritis. Clinical guidelines and this policy emphasize targeted use of multiplex panels for patients with features that increase pretest probability or would change management — for example, dysentery, moderate-to-severe disease (such as fever, dehydration, abdominal pain, or bacteremia), symptoms lasting more than 7 days, immunocompromised status, travel exposure, or suspected enteric fever — rather than routine testing of all patients with diarrhea.

Definitions and Symptom Lists

inv-22: Definition — Uninvestigated dyspepsia

DefinitionUninvestigated dyspepsia refers to dyspepsia that has not already been evaluated via investigations such as upper GI endoscopy and/or is not already classified as functional/organic dyspepsia.

ContextUsed to define eligibility for H. pylori testing when dyspepsia has not been previously investigated.

Exclusion notePatients with prior upper GI endoscopy or a defined organic/functional cause are not considered to have uninvestigated dyspepsia.

inv-23: Definition — Dyspepsia alarm features

DefinitionAlarm features include vomiting, bleeding or anemia, abdominal mass or unintended weight loss, and dysphagia.

Clinical implicationPresence of any alarm feature generally changes evaluation and may alter appropriateness of noninvasive H. pylori testing.

Policy Updates and Revision Notes

11/23creation

Policy developed and reviewed by external specialist.

02/24operational_update

Added 'lab' to title, removed CPT and ICD-10 codes from the policy reference table, and added a CPT code table while moving the 'coding implications' section.

03/24coding_correctionLatest

Policy Summary

PayerWellCare

PolicyCoding Implications — Syndromic Multiplex GI Pathogen Panels and H. pylori Testing (Outpatient)

Policy CodePolicy CG.CP.MP.04

Change TypeCoding table addedCPT description corrections

Effective Date

Next Review Date

Key ActionOrder syndromic multiplex GI panels or H. pylori tests only when outpatient clinical criteria are met and document supporting clinical indications.

SourceLink

On This Page

Symptoms of enteric fever (e.g., typhoid/paratyphoid fever)

Results of the testing will influence the member's/enrollee's clinical management.

Member/enrollee is younger than 60 years of age.

Does NOT have dyspepsia alarm features (e.g., unintended weight loss, gastrointestinal bleeding, palpable mass or lymphadenopathy).

Has NOT undergone previous investigation for dyspepsia.

Initiating prophylactic low-dose aspirin (e.g., following a major cardiovascular event).

Initiating chronic treatment with a non-steroidal antiinflammatory drug (NSAID).

Unexplained iron deficiency anemia despite an appropriate evaluation.

Adult with idiopathic thrombocytopenic purpura (ITP).

Documentation Required

Required Clinical Documentation

Documentation requirements: Providers must document outpatient presentation and the specific clinical criteria that justify use of a multiplex GI panel. Documentation should clearly state the indication (e.g., immunocompromised status, travel history, dysentery, fever, dehydration, abdominal pain/tenderness, bacteremia, prolonged diarrhea, or enteric fever symptoms) and how the test results will influence management.

Document outpatient setting and symptoms/signs supporting suspected infectious gastroenteritis.
Document which high-risk or clinical criterion is met (select from policy list).
Document anticipated impact of test results on treatment or infection control decisions.

Billing Rule

CPT Codes Referenced (No Additional PA Specified)

CPT codes referenced (no separate prior authorization specified): Use the listed CPT codes for billing multiplex GI and related infectious agent testing. Descriptions have been corrected in the coding section; bill using the specific CPT that matches the panel's target count and methodology. No additional PA beyond standard policy rules is indicated here, but frequency and documentation limits apply.

87505: Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
87506: ... 6-11 targets.
87507: ... 12-25 targets.
Use other listed CPTs (e.g., 87493, 87338, 87339, 83013, 83014) as applicable for H. pylori and other assays.

Denial Risk

Billing Guidance and Denial Risk

Corrected CPT code descriptions and billing guidance: The policy provides corrected CPT descriptions for nucleic acid infectious agent detection codes. Bill the specific CPT corresponding to the panel target count. Ensure documentation justifies the selected code. There are no explicit denial triggers listed here beyond standard medical necessity and documentation requirements; unsupported indications or testing outside the stated frequency may be denied.

Bill multiplex GI panels using CPT 87505 (3-5 targets), 87506 (6-11 targets), or 87507 (12-25 targets) as appropriate.
Other related CPTs: 87493, 87338, 87339, 83013, 83014, 87551, 87556, 87561, 87651–87653, 87797–87799, 87800–87801.
Denial risk: Testing outside the documented clinical criteria or more frequently than allowed ( >1 per 14 days per incident) may be denied.

Note

Provider Action / Administrative Notes

Provider administrative and coding notes: Surface operational items — ensure the CPT chosen matches the assay's target count and method (amplified probe, multiplex RT when performed). The policy corrected descriptions and removed obsolete codes; update billing systems accordingly. No additional explicit denial triggers are provided beyond medical necessity and frequency limits.

Confirm laboratory report and test order specify number of targets and methodology to select correct CPT.
Update internal charge masters to reflect corrected CPT descriptions and removed codes.
When in doubt, attach supporting clinical notes demonstrating outpatient presentation and chosen criterion.

Use in policySpecifies uninvestigated dyspepsia <60 years without alarm features as a criterion for H. pylori testing.

inv-24: Definition — Enteric fever symptoms

Symptoms listHigh fever; abdominal pain; constipation followed by diarrhea (sometimes bloody); flat 'rose spots' rash on abdomen/chest; confusion due to fever; hepatosplenomegaly; GI bleed/perforation.

Risk factorRecent travel or contact with a traveler from an endemic area increases suspicion for enteric fever.

Clinical relevanceEnteric fever symptoms are an indication for broader (12+ target) multiplex testing per policy.

inv-25: Code note — 87652 (nucleic acid detection) definition included

CPT 87652 descriptionInfectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification.

ScopeListed in the policy's corrected CPT coding implications table as a nucleic acid detection code.

Billing noteProviders should use the corrected CPT description from the policy when billing for 87652.

inv-26: Code note — 87653 (nucleic acid detection) definition included

CPT 87653 descriptionInfectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique.

ScopeIncluded in the policy's corrected CPT coding implications table for nucleic acid testing codes.

Billing noteUse the policy-listed description for 87653 when coding laboratory claims.

Corrected coding descriptions in the CPT table, removed CPT code 0369U, and corrected the policy number from CG.CP.MP.104 to CG.CP.MP.04.