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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 WellmarkNot 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:
    • direct exposure (e.g., family member)
    • relevant symptoms, or
    • asymptomatic patients for whom the testing would alter the course of care.
  • Testing of individual members that does not fall within the categories outlined under “Covered by Wellmark”. This would include:
    • a COVID-19 test obtained by a member without an order by a healthcare practitioner;
    • a COVID-19 antibody test requested by a member without known exposure, relevant symptoms or another clinically appropriate reason to order the test.
  • 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

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

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 Infectious agent antigen detection by immunoassay technique July 30, 2020

87635

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

March 13, 2020

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

ICD-10 Diagnosis Coding Guidance

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

*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

  • Modifier CS - For services furnished on March 18, 2020 through the HHS-declared public health emergency (currently expiring on Oct. 23, 2020), outpatient providers, physicians, and other providers and suppliers can use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services.

     

    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.

    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

     

  • For laboratory and specimen collection codes listed above

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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