Coverage of Congenital Cytomegalovirus (CMV) Screening - Florida Medicaid Health Care Alert 8/22/25

The Florida Agency for Health Care Administration (Agency) has updated the Medicaid Management Information System to reimburse for congenital cytomegalovirus (CMV) screening provided to newborns who meet the criteria outlined in Section 383.145, Florida Statutes, at a rate in addition to the hospital inpatient reimbursement for diagnostic related group (DRG) payment, in accordance with the Florida Medicaid Inpatient Hospital Services Coverage Policy.

Key Medicaid Information for Fee-for-Service and Managed Care Providers

Coverage of Congenital Cytomegalovirus (CMV) Screening

Section 383.145, Florida Statutes, states that CMV screening must be administered to each newborn admitted to the hospital as a result of a premature birth occurring before 35 weeks’ gestation, for cardiac care, or for medical or surgical treatment requiring an anticipated stay of 3 weeks or longer. The CMV screening must be initiated before the newborn becomes 21 days of age. If a newborn requires transfer to another hospital for a higher level of care, the receiving hospital must initiate the congenital cytomegalovirus screening if it was not already performed by the transferring hospital or birthing facility. For newborns transferred or admitted for intensive and prolonged care, the congenital cytomegalovirus screening must be initiated regardless of whether the newborn failed a hearing screening. Florida Medicaid currently covers congenital CMV screening under Current Procedural Terminology (CPT) code 87496 (CYTOMEG DNA AMP PROBE).

Hospitals and independent laboratories will be reimbursed for CMV screening in addition to the DRG payment and through the FFS delivery system regardless of the recipient’s enrollment in managed care with a Date of Service on or after July 1, 2024, when billed with a corresponding inpatient claim.

FFS claims for congenital CMV screening will pay the additional fee schedule amount listed below in addition to the DRG rate of the approved inpatient claim. To receive the additional payment, please submit adjustments for the FFS claims for CMV screening with dates of services on or after July 1, 2024.

Current rates for CMV screening

CPT Code 87496 | CYTOMEG DNA AMP PROBE (CMV Testing)

Fee Schedule $21.05

Submitting a FFS claim adjustment

• Submit Adjustment via X12 837 transaction: o Adjusted claims must contain a frequency code of “7” and the 13-digit ICN of the paid claim being adjusted in the REF02 segment of the X12 837 transaction.

• For additional information on the successful processing of adjustments, please refer to the EDI Companion Guides on the public Web Portal.

• For claims with Date of Service that exceed the 12-month claims submission time limited, providers must submit exceptional claims, along with the required Exceptional Claim Form, electronically via the Florida Medicaid Secure Web Portal under the Claims panel. Providers are encouraged to review the Electronic Exceptional Claim Submission Quick Reference Guide, found on the Quick Reference Guides page of the public Web Portal, for instructions on how to submit an electronic exceptional claim. For assistance on submitting exceptional claims, please visit the Agency’s Provider Services for detailed information.

Providers are encouraged to consult the updated fee schedule for billing information and guidance. For access to the current schedule and additional resources, visit: Rule 59G-4.190, F.S.C., Laboratory Services Coverage Policy.

Additional Information

Please contact the Florida Medicaid Provider Helpline Phone Number: 1-877-254-1055 if you need additional assistance.

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