 |
|
 |
| |
|
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:
- 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
|
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
|
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 |
COVID-19 Vaccine codes (Effective November 10, 2020)
Code |
Desc |
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.) |
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.) |
*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 (Effective November 10, 2020)
91300-product code |
Code |
Desc |
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 |
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 |
91301-product code |
Code |
Desc |
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 |
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 |
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
-
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
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
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.
|
 |
» Register now
I need secure access to:
Tools and resources related to:
- Claims
- Payment
- Benefits
- Authorizations
Take me there.
E-credentialing Central to access these tools:
- Application Tool
- Change Request Tool
- Recredentialing Tool
- Provider Directory Update Tool
- Submission Status Tracker
- Submission History Tool
- View my Organization
- Manage my Users
Take me there.
| |
 |