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Provider Billing Guidance for COVID-19 Testing

Medicare DRG Increases for COVID-19 Treatment Services Under Coronavirus Aid, Relief, and Economic Security (CARES) Act

The Centers for Medicare & Medicaid Services (CMS) have released guidance for implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (PDF). Health Net Health Plan of Oregon (Health Net) will be following this guidance as we adjudicate Medicare claims for applicable COVID-19 inpatient treatment services.

The CARES Act provides for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. The increase will be applied to claims that include the applicable COVID-19 ICD-10-CM diagnosis code and meet the date of service requirements, as follows:

For discharges with the diagnosis codes above, Health Net will follow the Medicare billing guidance published by CMS (PDF). Inpatient claims for these COVID-19 discharges that have already been received will be automatically reprocessed to reflect the payment increase.

This guidance is in response to the COVID-19 pandemic and may be retired at a future date.

SOURCES:

The Centers for Medicare and Medicaid (CMS)

The Centers for Disease Control (CDC)

New Telehealth Policies Expand Coverage for Healthcare Services

In order to ensure that all of our members have needed access to care, we are increasing the scope and scale of our use of telehealth services for all products for the duration of the COVID-19 emergency. These coverage expansions will benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to avoid clinical settings and other public spaces.

Effective immediately, the policies we are implementing include:

  • Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth*
  • Any services that can be delivered virtually will be eligible for telehealth coverage
  • All prior authorization requirements for telehealth services will be lifted for dates of service from March 17, 2020 through June 30, 2020
  • Telehealth services may be delivered by providers with any connection technology to ensure patient access to care**
  • Any provider claim with a date of service beginning 3/17/20 through 6/30/2020 will have $0 member liability
  • Any provider claim that is billed with a place of service of 02 will have $0 Member Liability
  • Any provider claim that is billed with the following modifiers regardless of place of service billed will also be in scope:
    • Modifier 95
    • Modifier GT
    • Modifier GQ
  • Any provider claim billed with the following HCPCS/CPT codes will also be in scope for e-visits (a communication between a patient and their provider through an online patient portal):
  • Medicare: 99421, 99422, 99423, G2061, G2062, G2063, G2010, G2012 
    • 99441, 99442, 99443, 98966, 98967, 98968 (these codes are effective 3/30)
  • Medicaid: 99441, 99442, 99443, G2010, G2012, 
    • 98966, 98967, 98968 (these codes are effective 3/30)
  • Any provider claim billed with the following revenue code:
    • 780 regardless of POS or modifiers (telemedicine unspecified)
    • 789 regardless of POS of modifiers
  • PLEASE NOTE: Medicaid Providers please follow your state specific guidelines for telehealth billing
  • Prior Auth requirements will also be waived to ease access of care requirements
  • This is regardless of diagnosis
  • This is across all product lines
  • This is inclusive of both Par and Non Par Providers
  • See the CMS Issued FAQ sheet (PDF) for additional information

*Please note: For Health Savings Account (HSA)-Qualified plans, IRS guidance is pending as to deductible application requirements for telehealth/telemedicine related services. 
**Providers should follow state and federal guidelines regarding performance of telehealth services including permitted modalities.

Providers who have delivered care via telehealth should reflect it on their claim form by following standard telehealth billing protocols in their state.

We believe that these measures will help our members maintain access to quality, affordable healthcare while maintaining the CDC’s recommended distance from public spaces and groups of people.

The AMA (Americal Medical Association) offers special coding advice during COVID-19 public health emergency. Read the AMA advice (PDF).

Information provided by the American Medical Association does not dictate payer reimbursement policy and does not substitute for the professional judgement of the practitioner performing a procedure, who remains responsible for correct coding.

Testing & Screening

COVID-19 Testing, Screening & Treatment Services

COVID-19 Testing Services

Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:

  • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel
  • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
  • CPT 87635 - Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”
    Please note:  It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.

High-Throughput Technology Testing Services

Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:

  • HCPCS U0003 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
  • Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
  • HCPCS U0004 -2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
  • Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.

Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.

We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.

Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Specimen Transfers

For specimen transfer related claims, the following codes can be used:

  • G2023 - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
  • G2024 - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
  • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.

Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

COVID-19 Screening Services

All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.

If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:

  • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
  • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation

This applies to services that occurred as of February 4, 2020.

Providers billing with these codes will not be limited by provider type.

COVID-19 Treatment Services

We will waive prior authorization requirements and member cost sharing for COVID-19 treatment for all members.

For dates of service from February 4, 2020 through March 31, 2020 providers should use the ICD-10 diagnosis code:

B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere

For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:

U07.1 – 2019-nCov Confirmed by Lab Testing

As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers.  For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply.

Reimbursement Rates for COVID-19 Services for All Provider Types

We are complying with the rates published by CMS for the following codes:

  • U0001 = $35.91
  • U0002 = $51.31
  • U0003 = $100.00
  • U0004 = $100.00
  • G2023 = $23.46
  • G2024 = $25.46

Commercial products will reimburse COVID-19 services in accordance with our negotiated commercial contract rates.

We will follow these CMS published rates except where state-specific Medicaid rate guidance should supersede.

Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.

Updated 5.15.2020