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As you navigate the day-to-day uncertainties of providing patient care during the COVID-19 outbreak, ensuring appropriate coding may not be top of mind for your clinicians. The following information and guidelines will help you answer any E/M coding questions and communicate best practices with your staff to keep your clinic as healthy as your patients.
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 December 23, 2020 at 10:44 am.
For proper reimbursement and so patients do not receive a bill inappropriately, it is imperative that the coding be correct for all COVID-19 related services.
Effective January 1, 2021, there are new ICD-10 codes for reporting COVID-19 related diagnoses. These codes replace the existing codes we are using that are not as specific.
|Condition||2020 ICD-10||2021 ICD-10|
|Encounter for screening for COVID-19||Z11.59||Z11.52|
|Contact with and (suspected) exposure to COVID-19||Z20.828||Z20.822|
|Personal history of COVID-19||Z86.19||Z86.16|
|Pneumonia due to coronavirus disease||U07.1 and J12.89||U07.1 and J12.82|
There are two other new codes:
For patients diagnosed with (MIS) and COVID-19, report U07.1 with M35.81 as an additional diagnosis.
If MIS develops as a result of a previous COVID19 infection, report codes M35.81 and B94.8, (Sequelae of other specified infectious and parasitic diseases).
If the provider does not document that the MIS is due to the previous COVID-19 infection, report codes M35.81 and Z86.16.
If the patient has a known or suspected exposure to COVID-19, and no current COVID19 infection or history of COVID-19, report codes M35.81 and Z20.822.
Additional codes should be assigned for any associated complications of MIS.
Practices should start using these new ICD-10 codes with date of service January 1, 2021.
In the 2021 release of the Official ICD-10 Guidelines, the National Center for Health Statistics (NCHS) added instructions for coding the diagnoses for COVID-19 related services. The updated guidelines differ slightly from the previous interim guidance.
The official guidelines are updated annually on October 1st.
Only confirmed cases as documented by the provider or confirmed by test results should be coded with ICD U07.1, COVID-19. This code should be the primary diagnosis on the claim. Codes for any acute respiratory manifestations due to COVID-19 should be additional diagnoses (e.g., pneumonia). This is also the case for non-respiratory manifestations caused by COVID-19.
|Pneumonia||U07.1 – COVID-19
J12.89 – Other viral pneumonia (J12.82 in 2021)
|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
Signs and symptoms without a definitive diagnosis should be reported with the code for each presenting problem. Some examples are:
This is not a comprehensive list. If the identified signs and symptoms is not on the list above, use the most appropriate ICD-10 available.
Report ICD Z20.828(Z20.822 in 2021), Contact with and (suspected) exposure to other viral communicable diseases, in addition to the symptoms to clarify that the services are COVID-19 related.
Asymptomatic patients with actual or suspected exposure should be coded with ICD Z20.828(Z20.822 in 2021).
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 Z20.828 (Z20.822 in 2021).
Diagnoses added to the guidelines are:
With the start of flu season, 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.
These CPTs were effective on 10/06/2020.
CPT 87428 was effective on 11/10/2020.
Most major payers are covering both 87635 and U0002 at the same rate. Medicare requires modifier QW (CLIA waived test).
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])).
Medicare requires modifier QW (CLIA waived test).
All the tests listed have a waived status. Modifier QW should be appended when the insurance plan requires it.
|Assure CoVID-19 IgG/IgM Rapid Test Device||Assure Tech. (Hangzhou Co., Ltd)||86328|
|CareStart COVID-19 Antigen Test||Access Bio, Inc.||87811|
|BinaxNOW COVID-19 Ag Card||Abbott Diagnostics Scarborough, Inc.||87811|
|LumiraDx SARS-CoV-2 Ag Test||LumiraDX UK Ltd.||87426|
|BD Veritor System for Rapid Detection of SARS-CoV-2||Becton, Dickinson and Company (BD)||87426|
|Sofia 2 SARS Antigen FIA||Quidel Corporation||87426|
|Cue COVID-19 Test||Cue Health Inc.||87635|
|ID NOW COVID-19||Abbott Diagnostics Scarborough, Inc.||87635|
|Xpert Xpress SARS-CoV-2 Test||Cepheid||87635|
|Accula SARS-Cov-2 Test||Mes Biotech Inc.||87635|
|cobas SARS-CoV-2 & Influenza A/B Nucleic Acid Test for use on the cobas Liat System||Roche Molecular Systems, Inc.||87636|
|BioFire Respiratory Panel 2.1-EZ (RP2.1-EZ)||BioFire Diagnostics, LLC||0202U|
|Xpert Xpress SARS-CoV-2/Flu/RSV||Cepheid||0241U|
|Sofia 2 Flu + SARS Antigen FIA||Quidel Corporation||87428|
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.
On 07/30/2020, CMS announced how to report services when providers discuss the importance of self-isolation after the patient is tested and prior to the onset of symptoms. A Counseling Check List was also issued that outlines what topics to cover.
Providers should report the appropriate E/M code based on time when more than fifty percent of the face-to-face time is spent providing this counseling. If services are performed via telehealth, use the total time the provider personally spends furnishing the service on the day of the visit, face-to-face and non-face-to-face.
|New E/M Code||Total Time||Established E/M Code||Total Time|
|99201||10 minutes||99211||5 minutes|
|99202||20 minutes||99212||10 minutes|
|99203||30 minutes||99213||15 minutes|
|99204||45 minutes||99214||25 minutes|
|99205||60 minutes||99215||40 minutes|
In addition to what was covered during counseling, total time should be reported in minutes with the time spent in counseling (e.g., total time spent with the patient was 20 minutes with 15 minutes spent counseling on the need for self-isolation). In this example, CPT 99202 would be reported for a new patient and CPT 99213 for an established patient.
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 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 for claims dated March 18, 2020 until the end of the Public Health Emergency (PHE).
The American Medical Association (AMA) created a new code set for COVID-19 vaccine services. They can be found in a new Appendix Q, which will be updated as new vaccines become available
The structure is different from other vaccines. Each unique vaccine will have its own administration codes(s), depending on the number of doses. The manufacturer and name of the vaccine will be specifically listed in CPT, along with the National Drug Code (NDC).
|Vaccine Administration||Manufacturer||Vaccine Code|
|0001A (1st dose)
0002A (2nd dose)
|0011A (1st dose)
0012A (2nd dose)
|0021A (1st dose)
0022A (2nd dose)
Providers should not bill for the product if they received it for free. In that case, only the administration codes would be reported.
All vaccines are reported with diagnosis code Z23 (Encounter for immunization).
Many prior restrictions have been relaxed for the duration of the PHE. Private payers have published effective periods.
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.
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.
The correct POS for these services is 11 (Office) or 20 (Urgent Care Facility) based on your contract.
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.
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.
These examples are typical coding for these service. It may vary by payer. Specimen collection is included if billing another E/M.
CDC Current Instructions for Coding COVID-19 Related Services: ICD-10 Official Coding and Reporting Guidelines October 1, 2020 through September 30, 2021.
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: Infectious 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.
AMA Guidance for Coding Scenarios Unique to PHE: Special coding advice during COVID-19 public health emergency.