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.

*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

Infusions and Injections

COVID-19 Vaccine codes

*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

**COVID vaccine administration is treated as an ACA preventative. As required by the CARES Act, there would be no member cost share for members of Non-Grandfathered plans. Grandfathered plans are not required to waive member cost-share for COVID-19 vaccine administration under the CARES Act. However, during the public health emergency declared by HHS, Wellmark has decided to waive member cost-share for its fully-Insured members of Grandfathered plans, and most self-funded Grandfathered plans have followed suit.

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

• Review the interim coding guidelines for dates of service prior to April 1, 2020.
• Review the final code guidelines effective for dates of service April 1, 2020 and after.
• Review the new ICD-10-CM diagnosis code*

*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, 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
  99072	Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease (not separately payable and will bundle with primary services)
  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 - Updated May 11, 2021

• Effective July 1, 2021, Inpatient treatment for COVID-19 will apply benefits according to member’s health plan. COVID-related treatment is still considered a covered benefit, but will be subject to any applicable member cost shares (deductible, coinsurance and/or copays).
• Some employer groups are self-funded, which means they may have chosen to extend the cost-share waiver for certain COVID-19 inpatient treatment care beyond 7/1/21. Please verify benefits by contacting Customer Service.