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36.4.9.11 Helicobacter Pylori (H. Pylori)
Testing for H. pylori using serology, stool, or breath is a benefit of the Texas Medicaid Program with the following clinical lab services (TOS 5) procedure codes: 5-83009, 5-83013, 5-83014, 5-86677, and 5-87338.
The interpretation/professional component (TOS I) is not considered separately for reimbursement.
H. pylori is accepted as an etiologic factor in duodenal ulcers, peptic ulcer disease, gastric carcinoma, and primary B cell gastric lymphoma. H. pylori testing can be indicated for symptomatic clients with a documented history of chronic/recurrent duodenal ulcer, gastric ulcer, or chronic gastritis. The history must delineate the failed conservative treatment for the condition.
H. pylori testing is not indicated or covered for any of the following:
• New onset uncomplicated dyspepsia.
•Dyspepsia responsive to conservative treatment (e.g., withdrawal of non-steroidal anti-inflammatory drugs [NSAID] and/or use of antisecretory agents).
•Screening for H. pylori in asymptomatic clients.
•Dyspeptic clients requiring endoscopy and biopsy.
H. pylori testing is not indicated under the following circumstances:
•There has been a negative endoscopy in the previous six weeks.
•An endoscopy is planned.
•H. pylori is of new onset and still being treated.
Serology testing is not indicated or covered for monitoring response to therapy. Serology testing is a benefit once per year when submitted for the same client by any provider with the appropriate diagnosis code.
If a follow-up breath or stool test is used to document eradication of H. pylori, medical record documentation must verify the history of the following previous complication(s):
•The client remains symptomatic after a treatment regimen for H. pylori.
•The client is asymptomatic after H. pylori eradication therapy but has a history of hemorrhage, perforation, or outlet obstruction from peptic ulcer disease.
•The client has a history of ulcer on chronic NSAID or anticoagulant therapy.
The following procedure codes will not be payable on the same date of service by the same provider: 5-86677, 5-83009, 5-87338, and either 5-83013 or 5-83014. Procedure codes 5-83013 and 5-83014 may be considered for reimbursement on the same day.
Reimbursement for the H. pylori serology, breath, and stool test is restricted to the following diagnosis codes:
Procedure codes 5-83013, 5-83014, and 5-87338 are also payable with diagnosis code 04186.
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