Coding During the Public Health Emergency

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 April 7, 2020 at 2:45 pm.

This is an unprecedented time in the healthcare industry both clinically and in the Revenue Cycle Management arena. While the county is hunkering in place, payors are covering services like never before to get your patients the medical attention they need without jeopardizing their health further.

On March 31, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule called the Medicare and Medicaid Program; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. This rule offered guidance for coding the new types of services that clinics are having to perform for access to care.

At this time, CMS and most payers are covering services related to COVID-19 including laboratory services. For most major payors, coverage is without cost to the patient. Telehealth services related to any diagnosis are often being reimbursed at the regular office setting rate. Even audio-only telephone calls are considered covered services, even by CMS.

To the best of our knowledge, no payer has announced they are not covering either COVID-19 related services or telehealth.

For providers, the important thing is to document your services accurately and to bill consistently.

Coding for COVID-19

Coding instructions are circulating regarding coding for COVID-19 and even laboratories are giving clinics incorrect coding information. Experity has provided the current coding information for diagnosis coding and laboratory testing below. We will continue to update as changes occur.

Diagnosis Coding

The Center for Disease Control (CDC) approved a new ICD-10 for COVID-19, U07.1, which become effective on April 1, 2020 for billing purposes. Instructions on use of this code were published in the ICD-10-CM Tabular List of Diseases and Injuries April 1, 2020 Addenda.

Positive Diagnosis of COVID-19

When a patient has a positive diagnosis of COVID-19, report U07.1 as the primary diagnosis and an additional ICD code to identify pneumonia or other manifestations (e.g., J12.81, Pneumonia due to SARS-associated coronavirus).

No Definitive Diagnosis of COVID-19

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

• R05– Cough
• R06.02– Shortness of breath
• R50.9– Fever, unspecified

Report Z03.18 or Z20.828 in addition to the symptoms so it is clear the services are COVID-19 related.

Diagnosis	ICD-10-CM
Possible Exposure to COVID-19	Z03.818 – Encounter for observation for suspected exposure to other biological agents ruled out
Actual Exposure to Someone Confirmed to Have COVID-19	Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases

 

Positive Diagnosis of COVID-19 on DOS March 31, 2020 and Prior

Prior to April 1, 2020, follow the interim guidance from the CDC for coding these health care encounters. Multiple codes may be required to accurately report the final diagnosis when confirmed as due to COVID-19.

The most important code to have on these claims is B97.29 (Other coronavirus as the cause of diseases classified elsewhere).

Diagnosis	ICD-10-CM
Pneumonia	J12.89 – Other viral pneumonia B97.29 – Other coronavirus as the cause of diseases classified elsewhere
Acute Bronchitis	J20.8 – Acute bronchitis due to other specified organisms B97.29 – Other coronavirus as the cause of diseases classified elsewhere
Bronchitis, Not Otherwise Specified (NOS)	J40 – Bronchitis, not specified as acute or chronic B97.29 – Other coronavirus as the cause of diseases classified elsewhere
Lower Respiratory Infection, NOS, or Acute Respiratory Infection, NOS	J22 – Unspecified acute lower respiratory infection B97.29 – Other coronavirus as the cause of diseases classified elsewhere
Respiratory Infection, NOS	J98.8 – Other specified respiratory disorders B97.29 – Other coronavirus as the cause of diseases classified elsewhere
Acute Respiratory Distress Syndrome (ARDS)	J80 – Acute respiratory distress syndrome B97.29 – Other coronavirus as the cause of diseases classified elsewhere

ICD-10-CM B34.2 (Coronavirus infection, unspecified) would be incorrect for COVID-19 since cases are respiratory and not unspecified. Code B97.29 should not be reported for cases described as “suspected”, “possible”, or “probable”.

The CDC’s complete interim coding guidelines for COVID-19 can be found at ICD-10-CM Official Coding Guidelines – Supplement Coding Encounters related to COVID-19 Coronavirus Outbreak Effective: February 20, 2020.

Laboratory Testing

Both CMS and the American Medical Association (AMA) issued procedure codes for testing for COVID-19. The three options are:

• U0001 – CDC 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel
• 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 ), amplified probe technique

The AMA’s guidance for reporting code 87635 can be found at AMA Fact Sheet: Reporting Severe Acute Respiratory Syndrome Coronavirus (SARS-Cov-2) Laboratory Testing.

HCPCS U0001 or U0002 should be reported to Medicare. Experity recommends reporting 87635 to all other payers when the amplified probe technique is used, and all other requirements of the description are met. Many major payers are covering both 87635 and U0002 at the same rate.

Tests Performed in the Clinic

In the last week several tests have come out that do not require an outside laboratory. Some are being sold pending approval from the Food and Drug Administration (FDA). At this writing, neither CMS nor AMA has published official guidance regarding reporting these services.

Approval is now an expedited process due to the public emergency. There are also fewer restrictions under the Clinical Laboratory Improvement Amendments (CLIA). CLIA has published a Frequently Asked Questions (FAQs), CLIA Guidance During the COVID-19 Emergency.

While we do anticipate coverage for these tests, Experity cannot comment on coverage for each unique type at this time.

For all payers, report HCPCS U0002 which includes any technique in the description.

We will keep you updated as more information becomes available.

Tests Sent to an Outside Laboratory

When the clinic is collecting the swab in the office and the test is billed by the lab, report 99000, Handling and/or conveyance of specimen for transfer from the office to a laboratory.

When the clinic is operating an external testing site and the test is billed by the lab, report 99001, Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated).

In the event your contract requires the test be billed by the clinic instead of the laboratory (i.e., pass through billing), report 87635 or U0002, as appropriate.

In the event your contract requires the test be billed by the clinic instead of the laboratory (i.e., pass through billing), report 87635 or U0002, as appropriate.

The correct Place of Service (POS) for these services are 11 (Office) or 20 (Urgent Care Facility) based on your contract. The services must be reported under the billable provider that is on site at the time of service (i.e., the physician or non-physician practitioner).

Laboratory Testing for COVID-19 on DOS March 12, 2020 and Prior

CPT 87635 became effective on March 13, 2020. Prior to this date, one of the HCPCS listed above, U0001 or U0002, would need to be reported.

Modifier for 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.

On April 7, 2020, CMS announced that evaluation and management 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 for claims dated March 18, 2020 until the end of the Public Health Emergency.

This is for Traditional Medicare only. This is not every visit, just the visit related to a decision to perform a COVID-19 lab test whether it is performed at that clinic or elsewhere.

The following instructions apply to all services regardless of diagnosis. The AMA has published guidance for specific scenarios Special coding advice during COVID-19 public health emergency.

Telehealth

Telehealth services is an area that is exploding currently. Many restrictions have been lifted considering the emergency, but this is generally for a stated period.

Locations

Telemedicine involves two separate locations and possibly two claims.

• Distant Site: This is the location of the provider is while furnishing the services.
• Originating Site: This is the location of the patient at the time the service is furnished. The patient is seen with the help of a telepresenter who remains with the patient while they are seen by the remote provider.

Due to shelter-in-place orders, most clinics will report only the distant site. A separate originating site fee is not always appropriate depending on where the patient is located (e.g., their home).

Billing

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

Traditional Coding

In the past, for the distant site, services are reported with POS 02 (Telehealth). The code would be an Evaluation and Management (E/M) code (99201-99215) as determined by the documentation. Three modifiers exist to report the equipment used for telemedicine services:

• GT (Via interactive audio and video telecommunication systems)
• 95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System)
• GQ (Via asynchronous telecommunications system)

The first two modifiers mean the same thing; one is published by CMS and the other belongs to the AMA.

New Instructions for Telehealth Effective March 31, 2020

Effective with the rule published on March 31, 2020, 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 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 will continue to be reimbursed at a lower rate.

At this time, these instructions have been published for Medicare. Private payers may vary.

Originating Site

While Experity does not anticipate receiving claims for the originating site, this would be reported with HCPCS code Q3014 (Telehealth originating site facility fee). The POS would be 11 or 20, as dictated by the insurance plan. Any diagnostic testing should be reported from the originating site.

The Center for Connected Health Policy (CCHP) is the best source for information on telemedicine services. Two important links are:

• Telehealth Coverage Policies in the Time of COVID-19
• COVID-19 Related State Actions

Telephone Calls (Audio Only)

Effective March 31, 2020, CMS began covering telephone calls. Many major private payers have already stated they will cover these services.

While Experity can make no guarantee that these services will be covered, we recommend reporting when documented.

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

Physician/Non-Physician Practitioner (NPP)

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

Other Providers

CMS has identified the types of providers that may report these codes are Licensed Clinical Social Workers (LCSW), clinical psychologists, physical therapists, occupational therapists, and speech language pathologists. They included the caveat that the visit must pertain to a service that falls within the benefit category of those practitioners.

For Medicare, when billing of these services by therapists include one of these modifiers: GO (Services delivered under an outpatient occupational therapy plan of care), GP (Services delivered under an outpatient physical therapy plan of care), or GN (Services delivered under an outpatient speech language pathology plan of care).

98966 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

98968 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management 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.

Other Services

There are other virtual services that may be more appropriate to clearly identify the services performed. Coverage will vary by payer.