We are complying with CMS coding guidelines for COVID-19 testing. The CDC is a reliable source for current testing information. As with any claim submission to the Health Plan, it is important that claims for COVID-19 testing be submitted with an accurate diagnosis code.
In most cases, the Health Plan does not cover COVID-19 testing when requested by a member or third party for reasons such as for employment, school admission, entertainment, or travel. Claims submitted for COVID-19 testing requested by a member or third party should include the appropriate diagnosis code from Z02.0 through Z02.9 as the primary diagnosis.
There is no copayment, coinsurance, or deductible for medically necessary COVID-19 tests when ordered by a provider during the public health emergency. Medically necessary testing includes tests for members with known or suspected symptoms or known or suspected exposure. It also includes tests for members entering a medical facility for services.
Effective October 1, 2021, the ICD-10 CM code used to report COVID-19 testing for asymptomatic and symptomatic patients with actual or suspected exposure to COVID-19 is Z20.822 – Contact with and (suspected) exposure to COVID-19. Per the ICD-10-CM Official Guidelines for Coding and Reporting, a screening code such as Z11.52 – Encounter for screening for COVID-19 is generally not appropriate during the COVID-19 pandemic.
For dates of service on and after March 18, 2020, Dean Health Plan requires modifier CS when billing E&M services related to the administration of a COVID-19 test or to the evaluation of a patient for purposes of determining the need for such a test. Modifier CS will allow us to accurately waive member cost share on services related to COVID-19 testing.
Providers may submit corrected claims to include modifier CS if member cost share was applied to a service related to COVID-19 testing on a previously-processed claim.
Telehealth service (either temporary or standard) is provided via Zoom or similar audio/visual technology Modifier: ’95 - indicating that the service rendered was actually performed via telehealth
Place of Service: Equal to what it would have been had the service been furnished in-person (eg, 11, 20, 21, 22)
Telehealth service (either temporary or standard) is provided via traditional method involving originating site and distant practitioner
Communication technology-based services
Communication technology-based services (CTBS) are furnished via telecommunications technology but are not considered telehealth services. Examples include telephone services (CPT 99441-99443, 98966-98968), online E/M services (99421-99423, G2061-G2063).
Because these are not considered telehealth services, a telehealth modifier is not required. The Place of Service should be ‘11’ or other applicable site of the practitioner’s normal office location.
Codes and travel allowance for specimen collection
For dates of service on and after March 1, 2020, Dean Health Plan accepts the following code for COVID-19 specimen collection:
The laboratory technicians must personally draw the sample and collect the specimen from a homebound or nursing home patient. Enlisting a messenger service for a specimen pick up does not qualify.
A travel allowance may be provided to laboratory technicians collecting specimens for COVID-19 testing from a non-hospital inpatient or homebound patients under existing codes P9603 and P9604.
Specimen collection code for hospital outpatient clinic visit
Effective for dates of service on and after March 1, 2020, CMS established a new Level II HCPCS code for COVID-19 specimens collected during a hospital outpatient clinic visit: HCPCS C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source.
COVID-19 testing using high throughput technologies
Effective on and after March 18, 2020, COVID-19 testing that uses high throughput technologies will be paid in accordance with CMS’ recently-released guidance. A high throughput technology is defined as a platform capable of automated processing of more than two hundred specimens per day. The highly sophisticated equipment requires more intensive processes and technician training to ensure quality and warrants a change in reimbursement.
Examples of high throughput technology as of April 14, 2020, include, but are not limited to, the following technologies:
As the public health emergency stabilizes, the Health Plan is determining appropriate timing for resumption of pre-COVID-19 operations.
Prevea360 Health Plan is waiving authorization requirements for outpatient services directly for and related to COVID-19. Providers must bill for these services using the COVID-19 ICD-10 codes to appropriately bypass authorization requirements for services that qualify for the waiver.
Prevea360 Health Plan does not require prior authorization for antibody testing; however, we do expect that all antibody tests be physician-ordered. Because of the variety of testing options available on the market currently, we encourage providers to know the efficacy of the antibody tests they are ordering.
Postponing elective surgeries and non-essential procedures
On March 18, 2020, CMS released a recommendation that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the COVID-19 outbreak for the preservation of personal protective equipment, beds, and ventilators. In response, Utilization Management is evaluating all approved prior authorizations on file for elective inpatient admissions with a surgery/admit date on or before March 16, 2020, to determine if the surgery was rendered:
Providers who are not equipped to handle COVID-19 patient inquiries or collect specimens for testing can contact us for the nearest in-network provider at DHP.PNCInquiry@deancare.com.
Providers who do not have access to a qualifying laboratory for COVID-19 testing can contact one of the following in-network FDA-approved laboratories:
We are referring to the CMS Medicare Telemedicine Health Care Provider Fact Sheet for our expanded telemedicine coverage guidance effective for dates of service beginning March 6, 2020. Our expanded coverage will remain in effect until further notice.
To support needed provider network adequacy, protect members and providers, and promote access to care, we are offering Zoom meeting licensure to providers without the ability to conduct telemedicine services during the COVID-19 public health emergency. Providers may contact their Provider Network Consultant if they are interested in obtaining a Zoom license to provide telehealth services.
To accommodate Medicare beneficiaries who don’t have access to or are hesitant to use the interactive audio-video technology required for telehealth services, the Centers for Medicare & Medicaid (CMS) is waiving the video requirement for certain telehealth services. Prevea360 Health Plan is adopting this waiver for all products during the public health emergency to allow members to receive these services via telephone (audio-only). The services that can be rendered via telephone have been added to CMS’s List of Medicare Telehealth Services.
Because practitioners are providing audio-only services in instances that would have been provided as in-person or telehealth visit under non-COVID-19 circumstances, CMS established new Relative Value Units (RVUs) for audio-only assessment and management services. The RVUs are based on crosswalks to the most analogous office/outpatient evaluation and management (E&M) services resulting in increased reimbursement for CPT codes 99441, 99442, and 99443. Prevea360 Health Plan is adopting the increased reimbursement rates for these codes on claims with dates of service on and after March 1, 2020, across all Prevea360 Health Plan products.
In alignment with CMS guidance, these temporary services should be billed with the Place of Service (POS) equal to what would have been billed if not for the public health emergency.
Modifier 95 should be appended to indicate that the service rendered was actually performed via telehealth. Traditional telehealth services performed using an originating-site facility and distant-site practitioner should continue to be billed with POS ‘02’.
Communication technology-based services
Communication technology-based services (CTBS) are furnished via telecommunications technology but are not considered telehealth services. Our coverage of CTBS services includes:
Telephone services (for all health plan products)