Panacea’s consultants have been closely monitoring both Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA) published guidance for newly created codes for billing during the COVID-19 public health emergency (PHE). Since February 2020, there have been many new codes added for COVID testing and specimen collection.

The AMA released four new codes on August 10, 2020. Two of the codes (86408, 86409) will be used to evaluate patients for SARS-CoV-2 antibodies prior to convalescent plasma donation, one code (0225U) is a new PLA (Proprietary Laboratory Analyses) test and one code (0226U) is a new high-throughput quantitative test developed by Ethos Laboratories. We are still awaiting payment status for these new codes from CMS either under the Clinical Laboratory Fee Schedule (CLFS) or the Hospital Outpatient Prospective Payment System (HOPPS). Likely this information will become available to hospitals and providers at the beginning of the fourth quarter of 2020.

The table below contains all added COVID-19 testing codes during the PHE. Where available we have included estimated payment and comments for some of the codes.

COVID-19 TEST CODES
HCPCS Medium / Long Description SI APC Relative Weight Payment Rate Comments for Use of Code
86328 Ia Infectious Agt Antibody SARS-CoV-2 COVID-19 A  $  45.23 for use with COVID single-step method
86408 Neutralizing Antibody SARS-CoV-2 Screen for testing antibody prior to convalescent plasma donation
86408 Neutralizing Antibody SARS-CoV-2 Titer for testing antibody prior to convalescent plasma donation
86769 Antb Severe Aqt Respir Synd SARS-CoV-2 COVID-19 A  $  42.13 for use with COVID multiple-step method
87426 Iaad Ia Severe Aqt Respir Synd Coronavirus A
87635 Iadna SARS-CoV-2 COVID-19 Amplified Probe Tq A  $  51.31
0202U Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2 A PLA code for COVD-19 – BioFire Panel
0223U Nfct Ds Bct/Vir Respir Dna/Rna 22 Trgt Sarscov2 A PLA code for COVID-19 – QIAstat-DX Panel
0224U Antb Sev Aqt Respir Synd
Coronavirus 2 Titer(S)
A PLA code for COVID-19 – Mt. Sinai Lab
0225U Nfct Ds Dna&Rna 21 Targets SARS-CoV-2 Amp Probe PLA code for COVID-19 – ePlex Panel
0226U Surogat Vir Neutrlzj Tst SARS-CoV-2 Elisa Plsm Srm PLA code for COVID-19 – Ethos Lab
U0001 CDC 2019 Novel Coronavirus  (2019-nCoV) Real-Time RT-PCR Diagnostic Panel A  $  35.91
U0002 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc A  $  51.31
U0003 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, making use of high throughput technologies as described by CMS-2020-01-R A  $100.00
U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R A  $100.00

 

The AMA published guidance on the use of the new immunology and PLA test codes (86408, 86409, 0225U, 0226U) can be found in their Special Edition CPT Assistant for August 2020. We are summarizing below some of the coding guidance and providing supportive information to assist hospitals and providers in determining the code that best describes the COVID-19 test being performed:

  • Codes 86408 and 86409 will be used when performing testing (screen) of patients who have recovered from COVID-19 and the donation center needs to confirm patient’s eligibility prior to donating for convalescent plasma. Codes 86408 and 86409 will help to determine that patient’s antibodies can directly block infection of cells. The AMA instructs users to continue to use code 86328 for immunoassay study when confirming the presence of COVID-19 antibodies.
  • Code 0225U is a new PLA test developed by GenMark Diagnostics called ePlex® Respiratory Pathogen Panel 2. This panel tests for 21 SARS-CoV-2 targets while codes 0202U (BioFire® Panel) and 0223U (QIAstat-Dx Panel) test for 22 targets. These PLA tests require a nasopharyngeal swab sample. Below we show the difference in the viral and bacterial targets for these PLA panels:
BioFire® panel QIAstat-DX panel ePlex® panel
PLA Code 0202U PLA Code 0223U PLA Code 0225U
Viral Targets
Adenovirus Adenovirus Adenovirus
Coronavirus 229E Coronavirus 229E Coronavirus 229E
Coronavirus HKU1 Coronavirus HKU1 Coronavirus HKU1
Coronavirus NL63 Coronavirus NL63 Coronavirus NL63
Coronavirus OC43 Coronavirus OC43 Coronavirus OC43
SARS-CoV-2 SARS-CoV-2 SARS-CoV-2
Rhinovirus/enterovirus Rhinovirus/enterovirus Rhinovirus/enterovirus
Metapneumovirus Metapneumovirus Metapneumovirus
Influenza A Influenza A Influenza A
Influenza A (subtype) H1 Influenza A (subtype) H1 Influenza A (subtype) H1
Influenza A (subtype) H3 Influenza A (subtype) H3 Influenza A (subtype) H3
Influenza A (subtype) H1-2009 Influenza A (subtype) H1-2009 Influenza A (subtype) H1-2009
Influenza B Influenza B Influenza B
Parainfluenza virus 1 Parainfluenza virus 1 Parainfluenza virus 1
Parainfluenza virus 2 Parainfluenza virus 2 Parainfluenza virus 2
Parainfluenza virus 3 Parainfluenza virus 3 Parainfluenza virus 3
Parainfluenza virus 4 Parainfluenza virus 4 Parainfluenza virus 4
Respiratory syncytial virus Respiratory syncytial virus Respiratory syncytial virus A
Respiratory syncytial virus B
Bacterial Targets
Bordetella parapertussis Bocavirus Chlamydophila pneumoniae
Bordetella pertussis Bordetella pertussis Mycoplasma pneumoniae
Chlamydia pneumoniae Chlamydophila pneumoniae
Mycoplasma pneumoniae Mycoplasma pneumoniae

 

  • Code 0226U is a high-throughput quantitative multi-step blocking ELISA assay that is designed to evaluate the patient’s viral inhibition capacity to SARS-CoV-2. This test requires a sample of the patient’s plasma. The Tru-Immune™ test was created by Ethos Laboratories in partnership with GenScript USA Inc. This test was approved under the Food and Drug Administration EUA (Emergency Use Authorization) for coronavirus testing.

There have been no further updates to coding and billing for COVID-19 specimen collection services. Panacea receives questions from time-to-time regarding other scenarios for collecting a nasopharyngeal swab specimen in specific sites, such as SNF (Skilled Nursing Facility) and RHC (Rural Health Clinic). Based on our understanding of the guidance CMS has published in the COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, we have summarized below the CMS guidance for these site scenarios:

  • Clinical staff in the SNF collect the nasopharyngeal swab specimen and testing is performed. CMS states specimen collection fee codes may not be billed for a SNF inpatient in a Part A stay, as the costs for tests (including sample collection) for those patients are already paid and covered as part of the stay.
  • Clinical staff in the RHC collect the nasopharyngeal swab specimen and testing is performed. CMS states specimen collection services are included in the all-inclusive rate for RHCs and are not paid separately, including a specimen collection for COVID-19 testing.

We remind hospitals and providers that collection of a nasopharyngeal swab specimen is not (or has never been) a covered service under Medicare benefits. Due to the COVID-19 PHE and under waivers granted under section 1135 of the Act, CMS was able to implement temporary payment for this method of specimen collection. CMS is now seeking stakeholder comments under its proposed rules for CY 2021 on whether to continue making separate payment for the specimen collection beyond the PHE.

The table below summarizes the collection specimen codes that have been added and are currently used during the PHE:

COVID-19 SPECIMEN COLLECTION CODES
HCPCS Medium / Long Description SI APC Relative Weight Payment Rate Comments for Use of Code
C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source Q1 5731 0.2845  $  22.99
G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source B not for hospital or provider use
G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]) from an individual in a snf or by a laboratory on behalf of a hha, any specimen source B not for hospital or provider use

 

Since the beginning of the PHE, coding and billing clarifications are being published at least weekly, so we advise hospitals and providers to continue to check CMS and AMA websites for new and updated guidance.

CPT is a registered trademark of the American Medical Association.
Copyright 2019 American Medical Association. All rights reserved.

 

Resources:

AMA CPT Assistant – Special Edition https://www.ama-assn.org/system/files/2020-08/cpt-assistant-guide-coronavirus-august-2020.pdf

AMA CPT Code Descriptors https://www.ama-assn.org/practice-management/cpt/covid-19-coding-and-guidance

COVID-19 Frequently Asked Questions on Medicare Fee-for-Service Billing https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf