ICD-10 Z13.9 is officially defined as "Encounter for screening, unspecified." code Z13.9 is referenced in 4 tracked payer policy changes from Medicare/CMS - LCD, Excellus BlueCross BlueShield, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Z13.9 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
CGS's LCD L34045 (Non-Invasive Vascular Studies), revised with an effective date of 11/5/2026, expands coverage to include arterial fibromuscular dysplasia (FMD) for non-invasive vascular studies, based on new literature and societal input supporting non-invasive testing for this condition. The revision is described as a coverage expansion rather than a restriction, with all other existing indications and limitations carried over from the prior version.
Excellus BlueCross BlueShield policy 2.02.42 covers chromosomal microarray analysis (CMA) for children with apparent nonsyndromic developmental delay or intellectual disability, autism spectrum disorder, or multiple anomalies not specific to a well-delineated genetic syndrome, and for pregnant patients undergoing invasive prenatal diagnostic testing. The 11/20/25 annual review removed the policy criteria for FMR1 gene analysis and the criterion that genetic test results have the potential to impact clinical management. The current effective date is November 20, 2025, and CMA used to confirm a disorder that is routinely diagnosed on clinical evaluation alone is considered not medically necessary.
Aetna considers serologic assay screening for antibodies to HSV-1 or HSV-2 in asymptomatic members, including those who are pregnant, experimental, investigational, or unproven because its effectiveness has not been established. The HSV CPT codes 86694, 86695, 86696, 87273, 87274, 87483, 87528 and 87529 are covered only when selection criteria are met, and 87483 and 87529 are not covered for asymptomatic members. CPT 87530 (HSV quantification) is not covered for the indications listed, and for HSV diagnosis in persons with active lesions or symptoms, qualitative PCR testing in CPB 0650 applies.
The February 2022 Health First Colorado provider bulletin (B2200475) covers several changes. Effective February 1, 2022, claims requiring electronic visit verification (EVV) go through pre-payment review, and claims without the needed EVV records may deny with EOB 3054. The bulletin also describes at-home OTC COVID-19 test billing under HCPCS E1399 with modifier U1 from January 15, 2022, requires the ordering provider's NPI on DMEPOS claims effective July 1, 2022, and notes that 24 physician-administered drug codes became subject to prior authorization effective January 18, 2022.
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