News
New Clinical Payment Policies Effective July 1, 2024 (Infectious Disease)
Date: 05/15/24
New Clinical Payment Policies Effective July 1, 2024: Infectious Disease - Lab Screening and Testing
Ambetter from Nebraska Total Care presents new clinical payment policies to provide payment protocols for Infectious Disease Primary and Preventive Care Lab Screenings and Lab Testing related to Infectious Diseases. The following policies have been posted to the Ambetter Clinical & Payment Policies page for review, prior to their implementation:
| POLICY | NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS | EFFECTIVE DATE |
|---|---|---|
CG.CC.PP.01 Concert Laboratory Payment Policy | This policy addresses laboratory services and applies to codes billed in an outpatient setting from the following sections in the AMA CPT/HCPCS Manual:
| 07/01/2024 |
CG.CP.MP.01 Infectious Disease: Respiratory Lab Testing | Seasonal influenza, respiratory syncytial virus (RSV), and SARS-CoV-2 infect many individuals each year. Diagnostic testing for upper respiratory tract infections can be very useful for clinicians, as clinical signs and symptoms of these infections can have significant overlap between pathogens. This policy outlines criteria for Syndromic/Multiplex Respiratory Panels with 6 or More Targets, SARS-CoV-2, RSV, or Influenza A/B, OR Multiplex Respiratory Viral Panels with 5 or Fewer Targets, Bacterial Respiratory Infection/Pneumonia Panels, Influenza A and B Antibody Tests, Group A Streptococcus Pharyngitis Tests, Group A Streptococcus Pharyngitis Cultures, and Group A Streptococcus Antibody Tests. | 07/01/2024 |
CG.CP.MP.02 Infectious Disease: Multi-System Lab Testing | Some pathogens cause infections with symptoms that affect a primary body system, while others cause infections that affect multiple body systems. This policy outlines the appropriate use of tests for pathogens that can cause multisystem symptoms and/or infections. Tests for pathogens that infect multiple body systems can be targeted to detect a specific pathogen(s) or non-targeted to broadly detect nucleic acid from any potential pathogen. | 07/01/2024 |
CG.CP.MP.03 Infectious Disease: Dermatologic Testing | Fungal infection of the nails (onychomycosis) is common. Confirmatory testing should be performed to confirm fungal infection before initiating treatment to prevent inappropriate use of antifungal medications. This policy outlines the appropriate use of Microscopy/Peroxidase Tests, Fungal Culture, and Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis. | 07/01/2024 |
CG.CP.MP.04 Infectious Disease: Gastroenterologic Lab Testing | Infections of the gastrointestinal (GI) tract represent a significant cause of infectious disease worldwide. GI infections can be caused by several pathogen types, including bacteria, viruses, fungi, and parasites (e.g., protozoal illnesses such as giardiasis). This policy outlines appropriate use of multi-pathogen panels, as well as diagnostic assays targeted at Helicobacter pylori (H. pylori). | 07/01/2024 |
CG.CP.MP.05 Infectious Disease: Primary Care & Preventative Lab Screening | In some instances, testing of healthy/asymptomatic individuals for infectious diseases is recommended as part of public health prevention and minimization of harm efforts. This policy outlines criteria for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS). | 07/01/2024 |
CG.CP.MP.06 Infectious Disease: Vector-Borne and Tropical Disease Lab Testing | This policy outlines criteria for Lyme disease and Zika virus testing via serologic and molecular methods. | 07/01/2024 |
CG.CP.MP.07 Infectious Disease: Genitourinary Lab Testing | Cultures, microscopic examination and molecular identification are all common testing methods for evaluating the infectious causes of various genitourinary conditions. This policy outlines criteria for Targeted Vaginitis/Vaginosis Pathogen Testing, Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels, Urine Culture for Asymptomatic Bacteriuria, and Molecular/Multiplex UTI Panels. | 07/01/2024 |
To review all clinical payment or payment policies, please visit the Ambetter Clinical & Payment Policies webpage.
For questions or additional information, please contact Provider Services at:
- Ambetter from Nebraska Total Care (Marketplace) 1-833-890-0329 (TTY: 711)
- Nebraska Total Care (Medicaid) 1-877-385-2192 (TTY: 711)
- Wellcare (Medicare) Non-Duals/C-SNP 1-800-977-7522 (TTY: 711)
- Wellcare (Medicare) Duals/D-SNP 1-844-796-6811 (TTY: 711)