UPDATE: CMS and AMA payment and coding guidance for COVID-19

Panacea has summarized the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) payment and coding updates being implemented during this public health emergency into the following sections:

General ICD-10-CM Coding Guidance
Factors Influencing Health Status & Contact with Health Services
Signs and Symptoms
2019-Novel Coronavirus (COVID-19) Laboratory Test & Payment
COVID-19 Emergency-Related Billing Policies and Procedures
Resources

2019-Novel Coronavirus (COVID-19) Diagnosis Coding

The coding guidance below was developed by CDC and approved by the four organizations that make up the Cooperating Parties: the National Center for Health Statistics, the American Health Information Management Association, the American Hospital Association, and the Centers for Medicare & Medicaid Services.

The CDC instructs providers to use this guidance in conjunction with the current ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding and Reporting (effective October 1, 2019). The guidelines will be updated to reflect new clinical information as it becomes available.

General ICD-10-CM Coding Guidance

Pneumonia

For a pneumonia case confirmed as due to the 2019 novel coronavirus (COVID-19), assign codes J12.89, Other viral pneumonia, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

Acute Bronchitis

For a patient with acute bronchitis confirmed as due to COVID-19, assign codes J20.8, Acute bronchitis due to other specified organisms, and B97.29, Other coronavirus as the cause of diseases classified elsewhere. Bronchitis not otherwise specified (NOS) due to the COVID-19 should be coded using code J40, Bronchitis, not specified as acute or chronic; along with code B97.29, Other coronavirus as the cause of diseases classified elsewhere.

Lower Respiratory Infection

If the COVID-19 is documented as being associated with a lower respiratory infection, not otherwise specified (NOS), or an acute respiratory infection, NOS, this should be assigned with code J22, Unspecified acute lower respiratory infection, with code B97.29, Other coronavirus as the cause of diseases classified elsewhere. If the COVID-19 is documented as being associated with a respiratory infection, NOS, it would be appropriate to assign code J98.8, Other specified respiratory disorders, with code B97.29, Other coronavirus as the cause of diseases classified elsewhere.

ARDS

Acute respiratory distress syndrome (ARDS) may develop in with the COVID-19, according to the Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (COVID-19) Infection.

Cases with ARDS due to COVID-19 should be assigned the codes J80, Acute respiratory distress syndrome, and B97.29, Other coronavirus as the cause of diseases classified elsewhere.

Factors Influencing Health Status & Contact with Health Services

For cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation, it would be appropriate to assign the code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out.

For cases where there is an actual exposure to someone who is confirmed to have COVID-19, it would be appropriate to assign the code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

Signs and Symptoms

For patients presenting with any signs/symptoms (such as fever, etc.) and where a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:

R05 Cough
R06.02 Shortness of breath
R50.9 Fever

Note: Diagnosis code B34.2, Coronavirus infection, unspecified, would in general not be appropriate for the COVID-19, because the cases have universally been respiratory in nature, so the site would not be “unspecified.”

If the provider documents “suspected”, “possible” or “probable” COVID-19, do not assign code B97.29. Assign a code(s) explaining the reason for encounter (such as fever, or Z20.828).

References:

CDC COVID-19 Clinical Care

CDC COVID-10 Evaluating and Testing PUI

2019-Novel Coronavirus (COVID-19) Laboratory Test & Payment

On February 4, 2020, the U.S Food and Drug Administration (FDA) issued an emergency use authorization (EUA) to allow emergency use of the Centers for Disease Control and Prevention’s (CDC) 2019-nCoV Real-Time RT-PCR Diagnostic Panel. Previously, this test was limited to use at CDC laboratories; however, as of February 4, 2020, the test can be used at any CDC-qualified lab in the U.S. to enable appropriate tracking and payment for the lab test. CMS established HCPCS code U0001 for use effective February 4, 2020, to describe this lab test. The code has been assigned to status indicator “A” (Not paid under OPPS. Paid by MACs under a fee schedule or payment system other than OPPS) in the April I/OCE. CMS also released test prices by MAC States/Territories. American Hospital Association (AMA) followed suit to quickly implement a laboratory test code. Hospitals will want to get this information set up in the laboratory chargemaster as soon as able. Ensure staff understands the AMA CPT code will be reportable to non-governmental payers and the CMS HCPCS codes are reportable to government payers (Medicare and Medicaid). Below is a table containing the new HCPCS codes and estimated payment. We have provided the applicable links for further review.

AMA HCPCS	2020 Long Description	March 13, 2020 SI	Estimated Payment
87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-10]), amplified probe technique	A	TBD
Per AMA coding instruction, if physician orders both nasopharyngeal swab and oropharyngeal swab and both specimens are tested then it is appropriate to report code 87635 x1 unit and 87635-59 x1 unit.
CMS HCPCS	2020 Long Description	February 4, 2020 SI	Estimated Payment
U0001	CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel	A	31.91
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

New CPT code COVID-19 testing. What you should know

CPT Assistant Guide Coronavirus

Press Release: CMS develops additional code coronavirus lab tests

COVID-19 Emergency-Related Billing Policies and Procedures

Medicare coverage or payment rules cannot be waived, even in a disaster or emergency. However, subject to certain pre-conditions being met, the Secretary of the Department of Health and Human Services may authorize the waiver or modification of certain requirements that relate to the Medicare, Medicaid, and the Children’s Health Insurance Programs under the authority of §1135 of the Social Security Act (Act), and some of these waivers or modifications may have an indirect effect on the application of Medicare fee-for-service coverage or payment rules in an emergency or disaster.

The preconditions that must be met before the Secretary can invoke the authority to waive or requirements under the §1135 authority are that:

The President must have declared an emergency or disaster under either the Stafford Act or the National Emergencies Act, and
The Secretary must have declared a Public Health Emergency under Section 319 of the Public Health Service Act.

Then, with respect to the geographic area(s) and time periods to which both of those declarations apply, the Secretary may elect to authorize waivers/modifications of one or more of the requirements described in Section 1135(b).

The implementation of such waivers or modifications is largely handled by CMS which determines whether and the extent to which sufficient grounds exist for waiving or modifying such requirements with respect to a particular provider, or to a group or class of providers, or to a geographic area within the emergency area.

Section 1135 and Section 1812(f) Waivers as a result of the Public Health Emergency (PHE), apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act:

The “DR” (disaster-related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.
The “CR” (catastrophe/disaster-related) modifier for Part B billing, both institutional and non-institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.

The following are instructions for institutional ambulance claims:

For institutional ambulance claims, CR modifier (to designate any service line item is disaster-related) is reported on the ANSI X12 837 Institutional claim format, this information would go in loop 2400 SV202-3 or SV202-4. On a paper claim, it would be entered in block 44 on the CMS UB-04 form.
For institutional ambulance claims, DR condition code (to designate the entire claim is disaster-related) is reported on the ANSI X12 837 Institutional claim format, this information would go in loop 2300 HI01-2. On a paper claim, it would be entered in blocks 24 -30 on the CMS UB-04 form.

Resources:

Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)

Coronavirus (COVID-19) Partner Toolkit

For information on policies and procedures only with a §1135 waiver

Coronavirus / Medicare Telehealth Frequently Asked Questions (FAQs)

Medicaid State Plan Fee-for-Service Payments for Services Delivered Via Telehealth