Quick Guide to E/M Coding for COVID-19

Billing Codes for Urgent Care: the Latest on COVID-19

Disclaimer Regarding Guidance on Coding and Billing for COVID-19 Related Services. The guidance set forth herein regarding coding and billing for COVID-19 related services is for educational purposes only and is based upon the limited information available to Experity at the time of publication. Nothing contained herein shall be deemed to constitute a representation, warranty or guaranty of proper coding or payment for any particular medical claim.  The sole responsibility for proper coding and submission of any particular medical claim remains with you.  You should consult with a certified professional coder and an attorney licensed in your state for guidelines specific to your state, contracts and applicable payors.

This is a living document that will be updated as this situation evolves. This version is current to what we know on November 4, 2021.

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Current COVID-19 Coding & Billing Guidelines

Diagnosis Coding

Positive Diagnosis of COVID-19

Only confirmed cases as documented by the provider or confirmed by test results should be coded with ICD U07.1. This code should be the primary diagnosis on the claim. Additional diagnoses should be used to report manifestations

Diagnosis	ICD-10-CM
Pneumonia	U07.1 – COVID-19 J12.82 – Pneumonia due to coronavirus disease
Acute Bronchitis	U07.1 – COVID-19 J20.8 – Acute bronchitis due to other specified organisms
Bronchitis, Not Otherwise Specified (NOS)	U07.1 – COVID-19 J40 – Bronchitis, not specified as acute or chronic
Lower Respiratory Infection, NOS, or Acute Respiratory Infection, NOS	U07.1 – COVID-19 J22 – Unspecified acute lower respiratory infection
Respiratory Infection, NOS	U07.1 – COVID-19 J98.8 – Other specified respiratory disorders
Acute Respiratory Distress Syndrome (ARDS)	U07.1 – COVID-19 J80 – Acute respiratory distress syndrome
Multisystem Inflammatory Syndrome (MIS)	U07.1 – COVID-19 M35.81 – Multisystem inflammatory syndrome
Other Involvement of Connective Tissue	U07.1 – COVID-19 M35.89 – Other specified systemic involvement of connective tissue

 

No Definitive Diagnosis of COVID-19

Symptomatic Patients

Signs and symptoms without a definitive diagnosis should be reported with the code for each presenting problem. Some examples are:

• R05.1-R05.9 – Cough
• R06.02 – Shortness of breath
• R50.9 – Fever, unspecified
• R68.83 – Chills (without fever)
• R69.89 – Rigors
• M79.10 – Muscle pain
• R51 – Headache
• J02.9 – Sore throat
• R07.0 – Pain in throat
• R43.0 – Loss of smell
• R43.9 – Loss of taste
• R19.7 – Diarrhea
• R11.0 – Nausea without vomiting
• R11.11 – Vomiting without nausea
• R11.2 – Nausea and vomiting
• R07.9 – Chest pain (central)
• R07.89 – Chest pain (anterior)
• R07.89 – Chest Pain (non-cardiac)
• R07.1 – Chest pain on breathing

Include ICD Z20.822 (Contact with and (suspected) exposure to COVID-19) in addition to the symptoms to identify the services as COVID-19 related.This is not a comprehensive list. If the identified signs and symptoms are not on the list above, use the most appropriate ICD-10 available.

Asymptomatic Patients

Asymptomatic patients with actual or suspected exposure should be coded with ICD Z20.822. Per the official guidelines, during the COVID-19 pandemic, a screening code is “generally not appropriate”. Even COVID-19 testing for preoperative testing should be coded as exposure, ICD Z20.822.

Late Effects of COVID-19

Use ICD U09.9 (Post COVID-19 condition, unspecified) for reporting sequela of COVID-19 or associated symptoms/conditions following a previous infection. This code should not be used for current infections. First code the current symptoms/conditions then add code U09.9 as a secondary diagnosis.

Additional Diagnoses

Other diagnoses include:

• History of COVID-19: Z86.16 (Personal history of COVID-19)
• Follow-up visits after COVID-19 has resolved without residual symptom(s) or condition(s): Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm), and Z86.16
• Encounter for antibody testing: Z01.84 (Encounter for antibody response examination)
• Screening for COVID-19: Z11.52 (Encounter for screening for COVID-19). This code is used when screening is required for administrative purposes (e.g., travel).

Vaccine Coding

The American Medical Association (AMA) created a new code set for COVID-19 vaccine services. The structure is different from other vaccines. Each unique vaccine has its own administration codes(s), depending on the number of doses.

Vaccine Administration	Manufacturer	Vaccine Code
0001A (1st dose) 0002A (2nd dose) 0003A (3rd dose) 0004A (Booster)	Pfizer, Inc.	91300   Original Formulation
0051A (1st Dose) 0052A (2nd Dose) 0053A (3rd Dose) 0054A (Booster)	Pfizer, Inc.	91305   Tris-sucrose Formulation
0071A (1st Dose) 0072A (2nd Dose)	Pfizer, Inc.	91307   Age 5-11 years
0011A (1st dose) 0012A (2nd dose) 0013A (3rd dose)	Moderna, Inc.	91301   100 mcg/0.5 mL dosage
0064A (Booster)	Moderna, Inc.	91306   50 mcg/0.25 mL dosage
0021A (1st dose) 0022A (2nd dose)	AstraZeneca, Plc	91302
0031A (Single dose) 0034A (Booster)	Janssen (Johnson & Johnson)	91303
0041A (1st dose) 0042A (2nd dose)	Novavax, Inc.	91304

 

Providers should not bill for the product since they receive it for free. Only the administration codes should be reported.

All vaccines are reported with diagnosis code Z23 (Encounter for immunization).

Report HCPCS M0201 in addition to the administration code for COVID-19 vaccine administration inside a patient’s home. Effective August 24, 2021, this code can be reported once for each patient vaccinated in a single home unit or communal space up to a maximum of 5 times if fewer than 10 patients are vaccinated on the same day in the same group living location.

When the sole purpose of the visit is to administer the vaccine, an evaluation and management (E/M) visit should not be reported separately. CPT 99211 (i.e., a minimal visit) captures the same services as the vaccine administration codes. Only the vaccine administration should be billed.

Until the Public Health Emergency (PHE) ends, include modifier CR on your claim if you administer the COVID-19 vaccine at a temporary location that isn’t considered your actual practice location.

Laboratory Testing

Combination Codes

Manufacturers have created single tests that detect both influenza A and B plus COVID-19, and, in some cases, respiratory syncytial virus. There are two types: one includes the polymerase chain reaction (PCR) test, the other includes the antigen test.

• 87636 – Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
• 87637 – Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique
• 87428 – Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitave; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B

Single Codes

PCR Test

• U0002 – 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes (includes all targets)
• 87635 – 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

Most major payers are covering both 87635 and U0002 at the same rate. Medicare requires modifier QW (CLIA waived test).

Antibody Testing

Point-of-care tests should be reported with CPT 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])).

Antigen Testing

• 87426 – Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severed acute respiratory syn drome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19])
• 87811 – Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Medicare requires modifier QW (CLIA waived test).

CPT/Laboratory Test Crosswalk

All the tests listed have a waived status. Modifier QW should be appended when the insurance plan requires it.

Test	Manufacturer	CPT
Accula SARS-Cov-2 Test	Mes Biotech Inc.	87635
Assure CoVID-19 IgG/IgM Rapid Test Device	Assure Tech. (Hangzhou Co., Ltd)	86328
BD Veritor System for Rapid Detection of SARS-CoV-2	Becton, Dickinson and Company (BD)	87426
BinaxNOW COVID-19 Ag Card	Abbott Diagnostics Scarborough, Inc.	87811
BioFire Respiratory Panel 2.1-EZ (RP2.1-EZ)	BioFire Diagnostics, LLC	0202U
CareStart COVID-19 Antigen test	Access Bio, Inc.	87811
cobas SARS-CoV-2 & Influenza A/B Nucleic Acid Test for use on the cobas Liat System	Roche Molecular Systems, Inc.	87636
Cue COVID-19 Test	Cue Health Inc.	87635
ID NOW COVID-19	Abbott Diagnostics Scarborough, Inc.	87635
LumiraDx SARS-CoV-2 Ag Test	LumiraDX UK Ltd.	87426
QuickVue SARS Antigen Test	Quidel Corporation	87811
Sofia 2 Flu + SARS Antigen FIA	Quidel Corporation	87428
Sofia 2 SARS Antigen FIA	Quidel Corporation	87426
Xpert Xpress SARS-CoV-2 test	Cepheid	87635
Xpert Xpress SARS-CoV-2/Flu/RSV	Cepheid	0241U

Specimen collection should only be reported when there is no other evaluation and management (E/M) code on the claim.

 

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Specimen Collection

Specimen collection should only be reported when there is no other evaluation and management (E/M) code on the claim.

CMS approved reporting 99211 for specimen collection for new and established patients.

Modifiers for COVID-19 Testing-Related Services

The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services.

E/M services that result in an order for or administration of a COVID-19 test, are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test should be billed with modifier CS for full payment. Patients should not be billed for these services.

This is effective until the end of the PHE.

Monoclonal Antibody COVID-19 Infusion

The Food and Drug Administration (FDA) authorized the use of monoclonal antibody therapies to treat mild-to-moderate COVID-19 when the patient has a positive COVID-19 test result and is at high risk for progressing to severe COVID-19, hospitalization, or both.

The therapies that have received an emergency use authorization (EUA) are:

• Casirivimab and imdevimab, administered together,
• Bamlanivimab and etesevimab, administered together, and
• Tocilizumab is only for use in the hospital setting.

The first two products are distributed free-of-charge by the Department of Health and Human Services (HHS) so the provider should only bill for the administration. Sotrovimab will not be distributed by the federal government so both the product code and the administration code should be reported.

Services Provided in the Urgent Care

Administration Code	Treatment	Manufacturer	Product Code
M0243 Initial Dose	Casirivimab and imdevimab, administered together (1200 mg or 2400 mg)	Regeneron	Q0243 (2400 mg) Q0244 (1200 mg)
M0240 Subsequent Repeat Dose(s)	Casirivimab and imdevimab, administered together (600 mg)	Regeneron	Q0240
M0245	Bamlanivimab and etesevimab, administered together (2100 mg)	Eli Lilly and Company	Q0245
M0247	Sotrovimab (500 mg)	GlaxoSmithKline	Q0247

 

Services Provided in the Home

Administration Code	Treatment	Manufacturer	Product Code
M0244 Initial Dose	Casirivimab and imdevimab, administered together (1200 mg or 2400 mg)	Regeneron	Q0243 (2400 mg) Q0244 (1200 mg)
M0241 Subsequent Repeat Dose(s)	Casirivimab and imdevimab, administered together (600 mg)	Regeneron	Q0240
M0246	Bamlanivimab and etesevimab, administered together (2100 mg)	Eli Lilly and Company	Q0245
M0248	Sotrovimab (500 mg)	GlaxoSmithKline	Q0247

 

The place-of-service (POS) for the home is 12. Other possible POS include 04 (Homeless Shelter), and 16 (Temporary Lodging).

The patient must have a positive COVID-19 test result and be at high risk for progressing to severe COVID-19, hospitalization, or both. Report ICD-10 code U07.1 (COVID-19) as primary with additional codes for any manifestations or high-risk conditions(s).

Casirivimab and imdevimab, administered together, are also authorized as a post-exposure prophylaxis (PEP). Coverage is limited to patients who are:

• not fully vaccinated or who are not expected to mount an adequate immune response (e.g., individuals with immunocompromising conditions including those taking immunosuppressive medications), and
• have been exposed to an infected individual as defined by the Centers for Disease Control and Prevention (CDC), or who are at high risk of exposure because of an infection in other individuals in the same institutional setting (e.g., nursing homes or prisons).

For PEP, use ICD Z20.822 as the primary diagnosis with additional codes for any immunocompromised conditions. Documentation should include the requirements above.

COVID-19 Coding Guidance for Telehealth (Audio and Visual)

Many prior restrictions have been relaxed for the duration of the PHE. Private payers have published effective periods.

Audio and Visual

CMS and many States have dictated that services be covered at the same rate as if the patient was in the clinic. Historically, CMS has covered these services at the lower facility rate due to decreased overhead.

CMS has instructed providers to bill with the same POS they would use if the patient had come to the office (i.e., 11 or 20). Modifier 95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) should be applied to indicate it was a telehealth service.

This coding ensures reimbursement at the appropriate non-facility rate. Claims submitted with POS 02 (Telehealth) will continue to be reimbursed at a lower rate.

These instructions are for payers that follow CMS guidelines. Instructions from private payers may vary.

Audio Only

Effective March 31, 2020, CMS began covering telephone calls. Many major private payers were already covering these services.

Documentation of time is used to support the level billed. Services can be reported for both new and established patients during the duration of the PHE.

• 99441 – Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
• 99442 – Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
• 99443 – Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

The correct POS for these services is 11 (Office) or 20 (Urgent Care Facility) based on your contract.

Online Digital Evaluation and Management Services (E-Visits)

• 99421 – Online digital evaluation and management, service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
• 99422 – Online digital evaluation and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
• 99423 – Online digital evaluation and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

This is for when a patient communicates with a provider via an EHR secure portal, secure e-mail or other digital application. It is for established patients but can be for a new problem. Services should be performed by a billable provider, not clinical staff.

Virtual Check-In

• G2012 – Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

This is a virtual check-in or brief communication technology-based service where the provider may respond to the patient’s concern by telephone, audio/video, secure text messaging, e-mail or use of a patient portal.

Virtual check-in services can only be reported when the billing practice has an established relationship with the patient.

 

COVID-19 Facility Coding & Billing Scenarios

These examples are typical coding for these services. It may vary by payer. Specimen collection is included if billing another E/M.

Employer Work Site

Specimen Collection Only

• CPT: 99211
• POS: 11 or 20 per your contract
• Facility: Office address

Nursing Facility

Specimen Collection Only

• CPT: 99211
• POS: 11 or 20 per your contract
• Facility: Office address

Onsite E/M Visit and Specimen Collection

• CPT: 99304 – 99310
• POS: 32
• Facility: Nursing facility address

Telehealth E/M Visits and Specimen Collection

• CPT: 99202-99215
• Modifier: 95
• POS: 11 or 20 per your contract
• Facility: Office address

Skilled Nursing Facility

Specimen Collection Only

• CPT: 99211
• POS: 11 or 20 per your contract
• Facility: Office address

Onsite E/M Visit and Specimen Collection

• CPT: 99304 – 99310
• POS: 31
• Facility: Skilled nursing facility address

Telehealth E/M Visits and Specimen Collection

• CPT: 99202-99215
• Modifier: 95
• POS: 11 or 20 per your contract
• Facility: Office address

Assisted Living Facility

Specimen Collection Only

• CPT: 99211
• POS: 11 or 20 per your contract
• Facility: Office address

Onsite E/M Visit and Specimen Collection

• CPT: 99324 – 99337
• POS: 13
• Facility: Assisted living facility address

Telehealth E/M Visits and Specimen Collection

• CPT: 99202-99215
• Modifier: 95
• POS: 11 or 20 per your contract
• Facility: Office address

Custodial Care Facility

Specimen Collection Only

• CPT: 99211
• POS: 11 or 20 per your contract
• Facility: Office address

Onsite E/M Visit and Specimen Collection

• CPT: 99324 – 99337
• POS: 33
• Facility: Custodial care facility address

Telehealth E/M Visits and Specimen Collection

• CPT: 99202-99215
• Modifier: 95
• POS: 11 or 20 per your contract
• Facility: Office address

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Sources

CMS COVID-19 Billing and Coding Toolkit: COVID-19

CDC Current Instructions for Coding COVID-19 Related Services: ICD-10 Official Coding and Reporting Guidelines October 1, 2021 through September 30, 2022

AMA List of Vaccine Codes: Find your COVID-19 Vaccine CPT^® Codes

AMA Guidance for Coding Scenarios Unique to PHE: Special coding advice during COVID-19 public health emergency

CMS Billing Information for Monoclonal Antibody COVID-19 Infusion: Monoclonal Antibody COVID-19 Infusion

AMA Guidance for Reporting Code 87635: AMA Fact Sheet: Reporting Severe Acute Respiratory Syndrome Coronavirus (SARS-Cov-2) Laboratory Testing

AMA Guidance for Reporting Code 86328: SARS-CoV-2 Serologic Laboratory Testing (Special Edition: April Update)

AMA Guidance for Reporting Code 0202U: TInfectious Disease Testing for Bacterial or Virus Respiratory Tract Infection (Special Edition: May Update)

AMA Guidance for Reporting Code 87246, 0223U, 0224U: Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV and SARS-CoV-2) Laboratory Testing (Special Edition: June Update)

AMA Guidance for Reporting Code 87636, 0241U: COVID-19 October Update

AMA Guidance for Reporting Code 87428: COVID-19 November Update