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COVID-19 Testing and Treatment

Wellmark is complying with the CMS, AMA and CDC coding guidelines for COVID-19.

More information is available at AMA Resource Center for Physicians.

Billing COVID-19 Tests to Wellmark

Wellmark pays for COVID-19 tests that are clinically appropriate and medically necessary for disease diagnosis and treatment purposes, after a physician or other licensed practitioner has individually assessed the member. The COVID-19 test must be ordered by the healthcare practitioner to be payable or reimbursable by Wellmark.

There are situations in which COVID-19 tests would not be considered medically necessary for an individual member, particularly for serologic/antibody tests. Guidance has recently been issued by the Department of Labor, the Department of Health and Human Services, and the Internal Revenue Service, as well as the Iowa Insurance Division that outlines situations in which it would be appropriate to bill a member’s health insurance and situations in which it would not be appropriate to bill a member’s health insurance. Wellmark has compiled the following table to assist providers identify when to bill Wellmark for COVID-19 tests, which applies to both Iowa and South Dakota providers.

 

Covered by Wellmark Not Covered by Wellmark
  • COVID-19 tests are covered by Wellmark when the member is under the care of a physician or other licensed practitioner who recommends and orders testing based on an individualized clinical assessment, which may include, but is not limited to, COVID-19 symptoms or known/suspected exposure.
  • Testing of individual members when some sort of an individualized clinical assessment has not been done.
  • Public health surveillance and other broad population-based serologic/antigen testing.
    • For example, serologic testing to meet university requirements for returning college students, regardless of symptoms or exposure, would not be covered by Wellmark.
  • Employee screening and COVID-19 testing for employment purposes, which is considered occupational health and the responsibility of the business and employee.*
  • Any other purpose not primarily intended for individualized diagnosis or treatment of COVID-19. Examples include testing to return to school or to play sports.

*On June 17, 2020, the Equal Employment Opportunity Commission released guidance that indicated employers could not legally require serologic/antibody testing of employees. Iowa businesses interested in performing PCR testing on employees to identify active COVID-19 infections should consult COVID-19 Testing Considerations for Iowa Businesses.

 

In all cases, COVID-19 tests must be approved or authorized by the FDA. Additionally, the COVID-19 test specimens must be collected in accordance with the manufacturer’s guidelines and processed in an Authorized Setting as designated by the FDA.

COVID-19 CPT & HCPCS Laboratory and Specimen Collection Codes

Code Description Effective Date of Service

C9803

Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19])

March 1, 2020

G2023

Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source

March 1, 2020

G2024

Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source

March 1, 2020

U0001

CDC 2019 novel coronavirus (2019-nCoV) real-time rt-pcr diagnostic panel

February 4, 2020

U0002

Non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19)

February 4, 2020

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

April 14, 2020

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)

April 14, 2020

XW033E5

Introduction of Remdesivir Anti-infective into Peripheral Vein, Percutaneous Approach, New Technology Group 5

November 10, 2020

XW043E5

Introduction of Remdesivir Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 5

November 10, 2020

0202U NFCT DS 22 TRGT SARS-COV-2 July 29, 2020
0223U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected July 30, 2020
0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed July 30, 2020
0240U NFCT DS VIR RESP RNA 3 TRGT October 6, 2020
0241U NFCT DS VIR RESP RNA 4 TRGT October 6, 2020

86318*

Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip);

April 10, 2020

86328

Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

April 10, 2020

86769

Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

April 10,2020

87426 Severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B July 30, 2020
87428 Infectious agent antigen detection by immunoassay technique November 10, 2020

87635

COVID-19 Infectious agent detection by nucleic acid (DNA or RNA); amplified probe technique

March 13, 2020

87636

SARSCOV2 & INF A&B AMP PRB

October 6, 2020

87637

SARSCOV2&INF A&B&RSV AMP PRB

October 6, 2020

87811

SARS-COV-2 COVID19 W/OPTIC

October 6, 2020

99000 Specimen handling July 30, 2020
99001 Specimen handling July 30, 2020

 

Infusions and Injections

Code Description Effective Date of Service

M0239

IV infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

November 10, 2020

M0243

Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring

November 21, 2020

Q0239

Injection, bamlanivimab-xxxx, 700mg

November 10, 2020

Q0243

Injection, casirivimab and imdevimab, 2400mg

November 21, 2020

 

COVID-19 Vaccine codes

Code Desc Effective Date
91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use (Vaccine manufacturer: Pfizer Inc.) Nov. 10, 2020
91301 SARS-CoV-2 (COVID-19) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage, for intramuscular use (Vaccine manufacturer: Moderna Inc.) Nov. 10, 2020
91303 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage, for intramuscular use (Vaccine manufacturer: Johnson & Johnson) Feb. 27, 2021

 

*When COVID-19 vaccine doses are provided by the government without charge providers can either

  • Bill only for the administration of the vaccine

OR

  • 1500 claim form – Apply zero charge to the line and append the SL modifier
  • UB claim form – Apply charge to the line and append the SL modifier

 

COVID-19 Vaccine Administration codes

91300-product code
Code Desc Effective Date
0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; first dose Nov. 10, 2020
0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; second dose Nov. 10, 2020
91301-product code
Code Desc Effective Date
0011A Immunization administration by intramuscular injection of SARS-CoV-2 (COVID-19) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; first dose Nov. 10, 2020
0012A Immunization administration by intramuscular injection of SARS-CoV-2 (COVID-19) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; second dose Nov. 10, 2020
91303-product code
Code Desc Effective Date
0031A Immunization administration by intramuscular injection of SARS-CoV-2 (COVID-19) vaccine, DNA, spike protein, Ad26 vector, preservative free, 5x1010 viral particles/0.5 mL dosage, single dose Feb. 27, 2021

 

ICD-10 Diagnosis Coding Guidance

The CDC has provided final coding guidance on ICD-10 diagnosis coding:

https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-19-508.pdf

*Note: ICD-10 code U07.1 is available for use for dates of service April 1, 2020 and after.

 

See COVID-19 FAQ provided by AHIMA and the AHA.

Waiver of Member Cost Share

Testing

  • Cost-sharing does not apply for COVID-19 testing-related services (see table below) which are medical visits that result in an order for, or administration of, a COVID-19 diagnostic test, but only to the extent that the items or services relate to the furnishing or administration of the test or to the evaluation of such individual for purposes of determining the need of the individual for the test as determined by the individual's attending health care provider.

     

    Modifier CS - For services furnished on March 18, 2020 through the HHS-declared public health emergency (currently expiring on April 21, 2021), outpatient providers, physicians, and other providers and suppliers can use the CS modifier on applicable claim lines to identify service(s) the provider believes would be eligible for the cost-sharing waiver for COVID-19 testing-related services. Note: inclusion of the CS modifier does not guarantee the cost-sharing waiver will apply – Wellmark reviews claims with the CS modifier to determine eligibility based on applicable diagnosis codes and CPT/procedure codes.

    COVID-19 Testing and Related Services Coverage

    Code Desc
    G0378 Hospital Observation Per Hr
    G0379 Direct admission of patient for hospital observation care
    G0382 Level 3 hospital emergency department visit provided in a type B emergency department
    G0463 Hospital Outpatient Clinic Visit For Assessment And Management of a patient
    G2023 Covid-19 - Speciman Collection, Any
    G2024 Covid-19 - Speciman Collection, In SNF-LAB
    G2025 Distant site tele svcs RHC / FGHC
    S9083 Global fee Urgent Care Center
    S9088 Services prov an urgent care center
    U0001 Covid-19 Lab Test Cdc
    U0002 Covid-19 Lab Test Non-Cdc
    U0003 Covid-19 = SARS-CoV-2 2019 CDC Test
    U0004 Covid-19 = SARS-CoV-2 2019 Non-CDC Test
    0100U Respir Pathogen 21 Targets
    36415 Collection Venous Blood Venipuncture
    71045 X-Ray Exam Chest 1 View
    71046 X-Ray Exam Chest 2 Views
    80048 Basic Metabolic Panel(Calcium Total)
    80053 Comprehensive Metabolic Panel
    85018 Blood Count; Hemoglobin, Coloriemtric
    85025 Automated Hemogram
    85027 Blood Count- Hemogram,Automated,With Platelet Count
    86140 C-Reactive Protein
    86317 Immunoassay For Infectious Agent
    86318 Immunoassay, Reagent Strip
    86328 Covid-19 Immunoassay, Reagent Strip
    36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick)
    86738 Mycoplasma
    86769 Covid-19 Antibody, Multiple Step
    87040 Culture, Bacterial, Definitive, Aerobic; Blood (May Include An
    87070 Culture, Bacterial, Definitive, Aerobic; Any Other Source
    87081 Culture, Bacterial, Screening Only, For Single Organisms
    87086 Culture, Bacterial, Urine; Quantitative, Colony Count
    87275 Influenza B Virus
    87276 Influenza A Virus
    87400 Influenza, A Or B, Each
    87420 Respiratory Syncytial Virus Antigen Detection By Eia
    87430 Streptococcus, Group A Antigen Detection By Eia
    87449 Infectious Agent Antigen Detection By Eia, Not Otherwise Speci
    87486 Chlamydia Pneumoniae, Amplified Probe Technique
    87502 Influenza Dna Amp Probe
    87503 Influenza Dna Amp Prob Addl
    87581 Mycoplasma Pneumoniae, Amplified Probe Technique
    87631 Iadna Respiratry Probe & Rev Trnscr 3-5 Targets
    87633 Iadna Respiratry Probe & Rev Trnscr 12-25 Target
    87634 Rsv Dna/Rna Amp Probe
    87635 Sars-Cov-2 Covid-19 Amp Pr
    87651 Streptococcus, Group A, Amplified Probe Technique
    87798 Infectious Agent Detection Nucleic Acid, Nos Amplified Probe T
    87801 Infectious Agent Detection By Nucleic Acid;Amplified Technique
    87804 Infectious Agent Antigen By Immunoassay;Influenza
    87807 Rsv Assay W/Optic
    87880 Streptococcus,Group A Detection Immunoassay W/ Optical Observa
    93000 EKG
    93005 EKG
    94640 Airway inhalation treatment
    94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination
    96360 Intravenous infusion, hydration
    96361 Intravenous infusion, hydration
    96365 Intravenous infusion, hydration
    96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis
    96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis
    96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis
    96369 Subcutaneous infusion for therapy or prophylaxis
    96370 Subcutaneous infusion for therapy or prophylaxis
    96371 Subcutaneous infusion for therapy or prophylaxis
    96375 Therapeutic, prophylactic, or diagnostic injection
    96376 Therapeutic, prophylactic, or diagnostic injection
    96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion
    99201 Office/Outpatient Visit, New
    99202 Office/Outpatient Visit, New
    99203 Office/Outpatient Visit, New
    99204 Office/Outpatient Visit, New
    99205 Office/Outpatient Visit, New
    99211 Office/Outpatient Visit, Est
    99212 Office/Outpatient Visit, Est
    99213 Office/Outpatient Visit, Est
    99214 Office/Outpatient Visit, Est
    99215 Office/Outpatient Visit, Est
    99217 Observation care discharge day management
    99218 Initial observation care
    99219 Initial observation care
    99220 Initial observation care
    99224 Subsequent observation care
    99225 Subsequent observation care
    99226 Subsequent observation care
    99281 Emergency Dept Visit
    99282 Emergency Dept Visit
    99283 Emergency Dept Visit
    99284 Emergency Dept Visit
    99285 Emergency Dept Visit

     

  • For testing and related services when appropriately billed with the following diagnosis codes regardless of sequencing of diagnosis (primary, secondary, etc.):
    • Possible exposure to COVID-19, ruled out Z03.818
    • Contact with COVID-19, Suspected exposure Z20.828
    • Asymptomatic, no known exposure, results unknown or negative Z11.59

     

    Diagnosis codes effective January 1, 2021

    • Encounter for screening for COVID-19, reported for people who are asymptomatic Z11.52
    • Contact with and (suspected) exposure to COVID-19 Z20.822
    • Pneumonia due to coronavirus disease 201), which includes the inclusion terms, “Pneumonia due to COVID-19” and “Pneumonia due to 2019 novel coronavirus (SARS-CoV-2)” J12.82
    • (Multisystem inflammatory syndrome) M35.81
    • Other specified systemic involvement of connective tissue M35.89

     

  • For laboratory and specimen collection codes listed above

 

Note: Wellmark may, in its discretion, apply other diagnosis codes to trigger cost-share waiver in combination with identified CPT/procedure codes.

 

Treatment

  • For treatment, the claim must have a COVID-19 diagnosis U07.1. Effective for admission dates of June 17, 2020, and after, the waiving of cost share will only apply to inpatient place of service.
  • The COVID-19 diagnosis does not have to be the primary diagnosis code but listed on the claim.
  • For treatment the cost share waiver applies to all Wellmark fully insured and Medicare Supplement members. Some self-funded plans that Wellmark administers may elect to require cost share of their members.

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