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Coding, Billing, and Paying for COVID-19 Testing

Coding, Billing, and Paying for COVID-19 Testing

NOTE: Additional guidance on coding and billing for COVID-19 testing was released after the article was initially published. For more current information, please refer to our article “Updated Guidelines for Billing COVID-19 Testing and Related Services.”


Just in time for wide-spread testing across the country, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have released new codes for COVID-19 testing. The IRS also will allow high deductible health plans to waive deductibles without jeopardizing patients’ eligibility to receive the tax benefits of contributing to their HSA, and many health plans have agreed to do just that. 

But the cost for COVID-19 testing may still be too high for many Americans. In this update, we talk about the details of billing for COVID-19 testing and how Americans will pay for it … or not.

The New Codes

CMS recently announced two new Healthcare Common Procedure Coding System (HCPCS) codes for SARS-CoV-2 testing. Beginning in April, laboratories performing the test can bill Medicare and other health insurers for services that occurred after February 4, 2020, using U0001 for tests by the Centers for Disease Control and Prevention (CDC) and U0002 for tests by non-CDC labs.

Meanwhile, the AMA announced last week that they have established code 87471 to be used for “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.” This code became effective March 13, the day it was published.

“Moving as quickly as possible to put in place a CPT code for a novel coronavirus test will bolster a data-driven response to the COVID-19 disease outbreak in the United States,” said AMA President Patrice A. Harris, MD, MA. “By streamlining the flow of information on novel coronavirus testing, a new CPT code facilitates the reporting, measuring, analyzing, researching and benchmarking that is necessary to help guide the nation’s response to the public health emergency.”

Providers should contact their local payers for billing instructions for using these new COVID-19 testing codes. According to the AMA, “The appropriate code to be reported is dependent upon the payer to which the claim is being submitted. If the claim is submitted to a payer that requires CPT codes, then code 87635 should be reported. Conversely, if the payer requires use of the HCPCS Level II code, the HCPCS Level II code should be reported. CPT and HCPCS codes should not both be reported on the same claim.”

The ICD-10 Coordination and Maintenance Committee announced that it would adopt the World Health Organization (WHO) code, U07.1 (COVID-19), effective April 1 for confirmed cases of the COVID-19 virus.

According to Decision Health Part B News, the committee had planned to wait until October 1 to implement the code in the U.S. But after COVID-19 was declared a pandemic by WHO, and President Trump declared a national emergency, Donna Pickett, head of the diagnosis coding side of the ICD-10 Coordination and Maintenance Committee, announced the date was moved to April 1.

Prior to April 1, providers should use the interim guidelines issued by the CDC, which outlines how to report illnesses caused by COVID-19.

Getting Paid

With the codes in place, how will they be reimbursed?

Medicare recently announced it will pay around $36 for the CDC tests and around $51 for the non-CDC tests, and as with other laboratory tests, Medicare beneficiaries will generally not have any cost sharing―at least not under original Medicare. CMS also directed Medicare Advantage and Part D prescription drug plans to waive cost-sharing for testing of COVID-19.

For most people with insurance, the test for COVID-19 will be covered by their plans based on the Families First Coronavirus Response Act passed by Congress and signed by President Trump on March 18, 2020, and copayments and coinsurance will be waived. According to Time Magazine, the law also requires insurers to cover “doctor’s office, urgent care, telehealth or emergency room visits as long as the services ‘relate to the furnishing or administration’ of a COVID-19 test or ‘for the evaluation of such individual for purposes of determining the need’ of a test.” 

As well, the IRS announced that health plans that cover the cost of the tests without a deductible will not jeopardize their status as “high deductible health plan,” which otherwise would have disqualified beneficiaries from being eligible to make tax-favored contributions to a health savings account (HSA). 

The same applies to treatment of COVID-19, and more and more payers are following through with commitments for just that. United Healthcare, Humana, Cigna, Aetna, Harvard Pilgrim, and Florida Blue have all announced they will waive cost-sharing for COVID-19 treatment. Several other payers are offering free telemedicine visits during the COVID-19 pandemic. As well, under the Families First Act, CMS has directed Medicare Advantage and Part D prescription drug plans to waive cost-sharing for treatment of COVID-19, including emergency room and telehealth visits.

For patients without insurance, COVID-19 tests also should be covered for free based on two provisions of the Families First Act. First, $1 billion was added to the National Disaster Medical System to reimburse medical providers for testing and diagnosing uninsured patients. Second, the law also provides additional funding for Medicaid, allowing states to cover COVID-19 testing for uninsured residents through that program.

The Hidden Costs

For many patients, the cost of being tested for COVID-19 could still be prohibitive, however. For instance, even for insured patients whose plans must provide COVID-19 testing at no cost, that doesn’t necessarily apply to tests for Influenza A and B, which often are conducted before COVID-19 tests are administered. 

Nor does it apply to office, clinic, or emergency department visit fees for patients who end up with a diagnosis other than COVID-19, fees which could add up to several hundred dollars and potentially be applied to a deductible or coinsurance. For uninsured patients in the same scenario, the costs would be even higher. And whether patients who visit out-of-network providers to be tested will receive bills also is unclear.

At least one hospital has made the tough decision to just test and treat patients and not worry about the billing … at least for now.

“We’ll figure it out on the back end. What we don’t want to do right now given the critical nature is delay things because of those issues,” said Dr. Rod Hochman, CEO of Renton, Wash.-based Providence, one of the nation’s largest not-for-profit healthcare systems, situated at the U.S.’s early epicenter of the COVID-19 outbreak. “We want to encourage people to get tested and we’ll figure that out on the back end, and for now we’re pausing on that just to really encourage people and make sure that’s not an impediment to them getting tested.”

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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