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Testing for SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) For AmeriHealth Pennsylvania Members (Updated December 15, 2022)

Policy Impacted



Purpose

The purpose of this communication is to provide advance notice regarding information and procedure codes related to testing for SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) for AmeriHealth Pennsylvania members. Additionally, this Company document identifies when coverage is provided for clinical purposes, and the nonco​vered instances such as public health surveillance & screening. ​
 

This communication addressing Testing for SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) shall remain in effect for a period of 90 days following the end of the State of Emergency as described in Executive Order 103.

Note: Information related to SARS-CoV-2 (Coronavirus Disease 2019 (COVID-19)) is continuously evolving. The Company is closely monitoring the outbreak caused by the novel coronavirus, and will update our communications accordingly. 

  • ​This document replaces the version published on February 18, 2022.
  • Procedure code 87913 has been added to this communication. 
  • Reimbursement for procedure code K1034 has been addressed.
  • ​Diagnostic testing analyzing breath samples has been addressed.
  • Revised FDA Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency has been highlighted.​


Background

​

There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has been detected both nationally and internationally. The virus has been named “SARS-CoV-2" and the disease it causes has been named “Coronavirus Disease 2019" (COVID-19). To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.

 
Centers for Disease Control and Prevention COVID-19 Testing
 
The Centers for Disease Control and Prevention (CDC) has developed a new laboratory test kit for use in testing patient specimens for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. The test kit is called the Centers for Disease Control and Prevention (CDC) 2019-Novel Coronavirus (2019-nCoV) Real-Time Reverse Transcriptase (RT)-PCR Diagnostic Panel. CDC's test kit is intended for use by laboratories designated by CDC as qualified, and, in the United States, certified under the Clinical Laboratory Improvement Amendments (CLIA) to perform high-complexity tests. This test is approved through the Emergency Use Authorization (EUA) processes of the U.S. Food and Drug Administration (FDA).

 
Emergency Use Authorizations (EUA) by THE FDA for COVID-19 Diagnostic Testing (RT-PCR and Antigen Testing) and Antibody Testing
 
Diagnostic Tests

Diagnostic testing for SARS-CoV-2 is intended to identify occurrence at the individual level and is performed when there is a reason to suspect that an individual may be infected, such as having symptoms or suspected recent exposure, or to determine resolution of infection.


RT-PCR
 
Recognizing the emergent circumstances related to this virus, the FDA has issued guidance to provide a policy for COVID-19 molecular diagnostics tests (e.g., RT-PCR) developed by laboratories certified to perform high-complexity testing under CLIA prior to issuance of Emergency Use Authorizations (EUA) for such tests. For a reasonable period of time after validation, and while they are preparing their EUA requests, the FDA does not intend to object to the use of these tests for specimen testing. This FDA EUA Process for COVID-19 testing includes certain diagnostic lab tests that use high-throughput technologies to rapidly diagnose large numbers of 2019 Novel Coronavirus (COVID-19) cases. Among several other technical, analytic, and clinical COVID-19 diagnostic RT-PCR test performance requirements, the FDA requires high levels of positive percent agreement (PPA)/sensitivity and negative percent agreement (NPA)/specificity. These parameters, generally, do not have a lower range below percentages in the nineties.


Antigen Tests
 
There is FDA EUA issuance for COVID-19 antigen testing, which is a category of diagnostic tests to detect fragments of proteins found on or within the virus. Among several other technical, analytic, and clinical COVID-19 diagnostic antigen test performance requirements, the FDA requires antigen tests should demonstrate a minimum sensitivity of ≥ 80% for all sample types submitted.


Other Diagnostic Tests for SARS-CoV-2

FDA also communicates about authorized SARS-CoV-2 diagnostic tests that analyze breath samples and have been authorized individually.​


Serology Tests (Antibody Tests)

These EUAs by the FDA also include serology testing to determine COVID-19 status from antibodies in blood samples (e.g., immunoglobulin G/immunoglobulin M (IgG/IgM), and includes rapid testing to detect antibodies against SARS-CoV-2 in serum, plasma, or venipuncture whole blood). The FDA details several requirements for the clinical agreement studies, for COVID-19 serological tests, which are intended to establish the performance characteristics for this antibody testing. Among several other technical, analytic, and clinical COVID-19 antibody test performance requirements, the FDA requires a minimum overall 90.0% PPA/sensitivity and overall 95.0% NPA/specificity. The FDA specifies other required values for each antibody type and combined parameters as well.


Revised FDA Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency

 

During Fall 2022, FDA announced updates to its COVID-19 test policy to address public health testing needs during this phase of the COVID-19 public health emergency. Over the last two years more than 400 COVID-19 tests have been granted emergency use authorization and there are generally enough at-home tests, tests that can be used at the point-of-care such as health clinics, and laboratory-based tests to meet testing needs. The FDA is revising its COVID-19 test policy to encourage most COVID-19 test developers to pursue a traditional premarket review pathway for their tests, rather than emergency use authorization. The FDA intends to prioritize its review of emergency use authorization requests on COVID-19 diagnostic tests that are likely to have a significant public health benefit or are likely to fulfill an unmet need. This could include novel technologies like the use of breath samples, or unique features like the ability of a test to detect a new SARS-CoV-2 virus variant. 

CDC Recommendations for Specimen Collection for Diagnostic COVID-19 Testing
 
For initial diagnostic testing for COVID-19, CDC recommends collecting and testing an upper respiratory nasopharyngeal swab (NP). Collection of oropharyngeal swabs (OP) is a lower priority and, if collected, should be combined in the same tube as the NP. Collection of only OP swab is acceptable if other swabs are not available. Collection of sputum should only be done for those patients with productive coughs. Induction of sputum is not recommended. CDC also recommends testing lower respiratory tract specimens, if available. For individuals who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. For individuals for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen. Specimens should be collected as soon as possible once an individual under investigation is identified, regardless of the time of symptom onset. Note that individual commercial lab tests may require collection of only one specimen type for initial diagnostic testing (nasopharyngeal OR oropharyngeal). For updated information go to: https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html.

 
At-Home Self-Sample Collection for COVID-19 Diagnostic Test
 
The FDA has begun authorizing diagnostic testing with a home specimen self-sample collection option for COVID-19. These self-collected samples must be tested and processed at approved laboratories for COVID-19 testing that is being performed within the FDA EUA guidance. As an example, the FDA re-issued the emergency use authorization (EUA) for the Laboratory Corporation of America (LabCorp) COVID-19 RT-PCR Test to permit testing of nasal swab samples self-collected by patients at home using LabCorp's Pixel by LabCorp COVID-19 Test home collection kit.

There is FDA EUA issuance that permits testing of saliva samples self-collected by patients at home using the FDA authorized COVID-19 diagnostic testing, which uses saliva samples to test for this virus in a healthcare setting.

The FDA's position is at-home processing tests cannot be utilized without an EUA for regulatory reasons outside of the scope of the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

 
Home Test Kits (Rapid or Instant Tests)
 
There are a number of at-home COVID-19 tests available. These tests may or may not be authorized for usage without a prescription. Any COVID-19 test intended for complete at-home testing requires an FDA-authorized EUA.
 

Differential Diagnosis

Because the signs and symptoms of the early stages of the COVID-19 disease are nonspecific, the differential diagnosis of COVID-19 infection may include the possibility of a range of common respiratory disorders, including: 

  • Adenovirus
  • Influenza
  • Human metapneumovirus (HmPV)
  • Parainfluenza
  • Respiratory syncytial virus (RSV)
  • Rhinovirus (common cold)


For suspected cases, ruling out other common respiratory pathogens may be necessary. 

  
PUBLIC HEALTH SURVIELLANCE AND SCREENING FOR COVID-19

 
Public Health Surveillance 
 
Surveillance for SARS-CoV-2 includes ongoing systematic activities, including collection, analysis, and interpretation of health-related data that are essential to planning, implementing, and evaluating public health practice. Surveillance testing is generally used to monitor for a community- or population-level occurrence, such as an infectious disease outbreak, or to characterize the occurrence once detected, such as looking at the incidence and prevalence of the occurrence. Surveillance testing is used to gain information at a population level, rather than an individual level, and results of surveillance testing can be returned in aggregate to the requesting institution. Surveillance testing may sample a certain percentage of a specific population to monitor for increasing or decreasing prevalence and to determine the population effect from community interventions, such as social distancing. An example of surveillance testing is a plan developed by a state public health department to randomly select and sample a percentage of all individuals in a city on a rolling basis to assess local infection rates and trends.

 
Screening 

Screening tests for SARS-CoV-2 are intended to identify occurrence at the individual level even if there is no reason to suspect infection—e.g., there is no known exposure. This includes, but is not limited to, screening of non-symptomatic individuals without known exposure with the intent of making decisions based on the test results. Screening tests are intended to identify infected individuals without, or prior to development of, symptoms who may be contagious so that measures can be taken to prevent further transmission. Currently, the CDC recommends for unvaccinated people to identify those who are asymptomatic and do not have known, suspected, or reported exposure to SARS-CoV-2. Screening helps to identify unknown cases so that measures can be taken to prevent further transmission. Examples of screening per the CDC include:

  • Testing employees in a workplace setting
  • Testing students, faculty, and staff in a school or university setting
  • Testing a person before or after travel
  • Testing at home for someone who does not have symptoms associated with COVID-19 and no known exposures to someone with COVID-19 ​​


Coverage Statement

​

The Company follows federal, state and local regulatory guidance related to COVID-19 testing. COVID-19 tests will only be covered when ordered by a healthcare professional licensed and/or authorized to do so under state law.

 
SPECIMENS COLLECTED BY A HEALTHCARE PROFESSIONAL
 
 
Diagnostic COVID-19 Testing (RT-PCR, Antigen Tests, or Other Diagnostic Tests for SARS-CoV-2 (e.g., tests that analyze breath samples))

 
The Company will cover (i) certain diagnostic COVID-19 tests (diagnostic RT-PCR and antigen tests), including COVID-19 tests that have been approved, cleared, or authorized by the FDA or for which the developer has requested, or intends to request, Emergency Use Authorization (EUA) for the COVID-19 pandemic; and (ii) the administration of such tests, when ordered by a licensed health care provider and performed at an approved healthcare setting. (This includes drive through testing). Such testing will only be covered if medically appropriate as determined by the member's health care provider in accordance with accepted standards of current medical practice. We recommend that health care providers confirm with the Company if such lab is an authorized and/or contracted lab and if they have the ability to perform such testing. Diagnostic COVID-19 testing will be covered for:

  • Individuals with signs or symptoms consistent with COVID-19
  • Asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission

 
When ordered by a healthcare provider, the Company will cover medically necessary diagnostic pooled testing only for testing that is associated with Company members' samples.


Antibody COVID-19 Testing
 
The Company will cover (i) certain antibody COVID-19 tests including COVID-19 tests that have been approved, cleared, or authorized by the FDA or for which the developer has requested, or intends to request, Emergency Use Authorization (EUA) for the COVID-19 pandemic; and (ii) the administration of such tests, when ordered by a licensed health care provider and performed at an approved healthcare setting. (This includes drive through testing). Such testing will only be covered if medically appropriate as determined by the member's health care provider in accordance with accepted standards of current medical practice. We recommend that health care providers confirm with the Company if such lab is an authorized and/or contracted lab and if they have the ability to perform such testing. Currently, antibody testing for COVID-19 has clinical support in these scenarios, and will be covered when:

  • Antibody tests are used to support the clinical assessment of COVID-19 illness for individuals who are being tested 9 to 14 days after illness onset, in addition to recommended virus detection methods such as PCR. This may maximize sensitivity as the sensitivity of nucleic acid detection is decreasing and serologic testing is increasing during this time period.
  • Antibody testing is being used to help establish a clinical picture when individuals have late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.
  • Neutralizing antibody screening and titer testing, and surrogate viral neutralization testing are used exclusively for the purpose of convalescent plasma administration during a hospital admission at the decision of the individual's medical providers. 

 
Antibody test results should not be used to diagnose someone with an active infection.

 
NONPRESCRIPTION OVER-THE-COUNTER (OTC)/DIRECT-TO-CONSUMER (DTC) DIAGNOSTIC COVID-19 TESTING

Reimbursement may be provided for 08 tests per member per calendar month for nonprescription over-the-counter (OTC)/direct-to-consumer (DTC) diagnostic COVID-19 tests, which have received emergency use authorizations by the FDA. Reimbursement for additional diagnostic tests, beyond this number of tests, will require a prescription from a healthcare provider.

 
Coverage of nonprescription OTC/DTC COV​ID-19 tests is provided either through the member's pharmacy benefit, or medical benefit as detailed in the following Company communications (as they apply to members of AmeriHealth Pennsylvania & AmeriHelath Administrators : 

  • https://www.amerihealth.com/htdocs/custom/covid-19/index.html​ (refere to the Testing Section)
  • https://www.amerihealth.com/htdocs/custom/covid-19/pdfs/test-faq.pdf​


Diagnostic OTC/DTC COVID-19 tests with FDA EUAs are not covered or reimbursed for screening. Screening includes - but is not limited to - the following per the CDC:

  • Testing employees in a workplace setting
  • Testing students, faculty, and staff in a school or university setting
  • Testing a person before or after travel
  • Testing at home for someone who does not have symptoms associated with COVID-19 and no known exposures to someone with COVID-19​


REQUIREMENTS REGARDING FDA AUTHORIZATIONS FOR COVID-19 TESTING


A developer's COVID-19 diagnostic or antibody test kit will be considered non-covered unless (i) the FDA approves the test for use; (ii) the developer has submitted an Emergency Use Authorization application (EUA) to the FDA for approval during the time of the public health emergency (or intends to do so within a reasonable period of time, which is currently 15 days for RT-PCR and antigen tests and 10 days for serology (antibody tests)*; or (iii) the test was developed in and authorized by a State that has notified the Secretary of Health and Human Services of its intention to review tests intended to diagnose COVID-19.


*The FDA expects commercial manufacturers to submit Emergency Use Authorization (EUA) requests, including their validation data, within 10 days of publication of the updated policy or the date they notify the FDA of their test validation, whichever is later.
 
If the FDA denies an EUA application for a COVID-19 diagnostic or antibody test or the test's developer fails to timely submit the EUA to the FDA for approval, the test will no longer be covered.

A diagnostic or antibody COVID-19 test will not be covered if does not meet the requirements, including technical, analytic, and clinical performance measures, detailed by the FDA in the most recent version of Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency -- Immediately in Effect Guidance for Clinical Laboratories, Commercial Manufacturers, and Food and Drug Administration Staff.
 
Authorized labs must notify local public health authorities before initiating testing with a COVID-19 diagnostic or antibody test kit, follow the terms and conditions described in the applicable EUA for an approved at-home diagnostic or antibody test kit, and administer the test in accordance with the applicable test procedures referenced therein.

Lab specimens for members enrolled in HMO and HMO-POS products may need to be sent to a different in-network approved laboratory, which is not the member's designated capitated laboratory site, when the designated capitated laboratory site does not have the ability to perform the COVID-19 test.


Referral and out of capitation authorization requirements have been waived for COVID-19 Laboratory Testing HCPCS codes U0001, U0002, U0003, U0004, U0005, G2023, G2024, and CPT codes 0202U, 0223U, 0224U, 0225U, 0226U, 0240U, 0241U, 86328, 86408, 86409, 86413, 87428 , 86769, 87246, 87635, 87636, 87637, and 87811.


Laboratory Corporation of America® Holdings (LabCorp), the national outpatient laboratory provider for the Company, is equipped to process diagnostic (RT-PCR) and antibody (IgG) COVID-19 specimen testing for our members. Details are available on the LabCorp website available at:


Laboratory Testing for COVID-19 Differential Diagnosis

The Company will cover testing of other clinically relevant respiratory pathogens, for the differential diagnosis of COVID-19. These tests include testing of the following pathogens through any clinically established method: 

  •  Adenovirus
  • Influenza
  • Human metapneumovirus (HmPV)
  • Parainfluenza
  • Respiratory syncytial virus (RSV)
  • Rhinovirus (common cold)


Referral and out of capitation authorization requirements have also been waived for COVID-19 Differential Diagnosis Laboratory Testing procedure codes when performed in conjunction with COVID-19 Laboratory Testing.

 
SPECIMEN COLLECTED BY AN AUTHORIZED WORKER FROM HOME HEALTH AGENCIES 


To help reduce potential exposure of COVID-19, the Company is waiving the requirement that a member be homebound for the purpose of laboratory specimen collection for diagnostic COVID-19 testing in their home.
 

In response to the COVID-19 outbreak, home specimen collection for diagnostic COVID-19 and related diagnostic respiratory pathogens' testing is considered medically necessary and, therefore, covered when all of the following criteria are met:

  • The specimen is collected by a nurse from a home health agency or by a trained laboratory technician.
  • The requirement that a member must be homebound (as defined in the medical policy) is waived, in order to receive a nurse visit from a home health agency for the purpose of laboratory specimen collection for COVID-19 testing in their home.
  • The specimen collection is medically necessary for the individual's condition and has been ordered by an eligible professional provider.
  • The specimen will be delivered to the appropriate Company participating laboratory to perform the test and send the results to the prescribing professional provider.

  
SPECIMENS COLLECTED BY A MEMBER:
 
Testing of Samples Self-Collected by Members 
 
The Company will cover testing of samples self-collected by members when the testing is conducted at FDA-approved locations as detailed in the EUA (including home), and all FDA EUA Requirements are followed for the specific test being administered. This includes self-collection materials (including kits) and other related equipment having received specific FDA EUA approval.

For example, the FDA re-issued the Emergency Use Authorization (EUA) for the Laboratory Corporation of America (LabCorp) COVID-19 RT-PCR Test to permit testing of samples self-collected by members at home using LabCorp's Pixel by LabCorp COVID-19 Test home collection kit.


 ROUTINE COVID-19 TESTING 

 
In Advance of Procedures 

 
Reimbursement for routine COVID-19 laboratory testing, for asymptomatic and/or nonexposed individuals, (e.g., preadmission testing; screening prior to procedures as part of an institutional protocol) is reimbursed as part of the procedural or surgical payment and is not eligible for separate reimbursement.

 
Testing of Nursing Home Residents and Patients

 Based on the evolving recommendations from the CDC for Testing Guidelines for Nursing Homes, (https://www.cdc.gov/coronavirus/2019-ncovs/hcp/nursing-homes-testing.html), Centers for Medicare & Medicaid Services (CMS) has issued communications for COVID-19 testing for nursing home residents and patients.

Reimbursement of routine COVID-19 testing in these contexts is reimbursed as part of the per diem payment to the facility and is not eligible for separate reimbursement for members admitted to skilled nursing facilities for short-term medical or rehabilitation purposes.
 
PUBLIC HEALTH SURVELLIANCE AND SCREENING

The Company does not cover COVID-19 testing when the primary purpose of this testing is for public health surveillance and/or screening. This includes tests using pooling methodologies or any others with a current FDA EUA.

 
REQUIRED DOCUMENTATION
 
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. This includes verification that laboratory or home test kits have been approved, cleared, or authorized by the FDA and/or that the developer has adequately abided by the FDA guidance before and after formally requesting EUA for the COVID-19 testing, including – but not limited to – test validation standards, reporting requirements, clinical testing to establish acceptable performance characteristics, and timeline adherence. This also includes review of any tests whose EUA has been revoked by the FDA.
 
All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
 
BILLING REQUIREMENTS​

Eligible professional providers performing SARS-CoV-2 (COVID-19) laboratory testing must report the most appropriate procedure code to represent the method of testing used. Additionally, the clinically appropriate diagnosis code(s) must be reported to support the testing being performed (e.g., diagnosis code(s) representing CDC listed signs and symptoms &/or required exposure to COVID-19 must be reported for any diagnostic testing). 


Eligible professional providers performing diagnostic pooled SARS-CoV-2 (COVID-19) laboratory testing must report the most appropriate procedure code to represent the method of testing used and only one unit of service for each of the Company's members tested. ​





​

Coding


DIAGNOSTIC TESTING FOR COVID-19 (e.g., through RT-PCR)
 

HCPCS codes U0001 and U0002, representing CDC and non-CDC testing, respectively, for SARS-CoV-2 (COVID-19) are effective and must be used for dates of service as of February 4, 2020 and after.

 

  • U0001: CDC 2019 novel coronavirus (2019-nCoV) Real-Time RT-PCR diagnostic panel
     
  • U0002: 2019-nCoV coronavirus, SARS-CoV-2 /2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

Note: HCPCS code U0002 can apply to all types of COVID-19 laboratory testing (e.g., RT-PCR, diagnostic breath test, or antibody testing).


 
HCPCS codes U0003 and U0004, for SARS-CoV-2 (COVID-19) laboratory testing using high throughput technologies, are effective and must be used for dates of service as of April 14, 2020 and after.

 

  • 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
     
  • 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

Note: HCPCS code U0004 can apply to all types of COVID-19 laboratory testing (e.g., RT-PCR, or antibody testing).​



HCPCS code U0005 for SARS-CoV-2 (COVID-19) laboratory testing using high throughput technologies, completed within 2 calendar days from date of specimen collection, is effective and must be used for dates of service as of January 01, 2021 and after.


  • U0005: 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, cdc or non-cdc, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either hcpcs code U0003 or U0004) as described by CMS-2020-01-R2

 

CPT code 87635 for SARS-CoV-2 (COVID-19) nucleic acid testing is effective and must be used for dates of service as of March 13, 2020 and after. 

 

  • 87635

 

CPT code 87913 for mutation identification in targeted region(s)​ for SARS-CoV-2 (COVID-19) through nucleic acid testing is effective and must be used for dates of service as of February 21, 2022 and after. 

  • 87913

​

CPT code 0202U for BioFire® Respiratory Panel 2.1 (RP2.1) testing manufactured by BioFire® Diagnostics, LLC is effective and must be used for dates of service as of May 20, 2020 and after. 


  • 0202U

 

CPT codes 0223U for QIAstat-Dx Respiratory SARS CoV-2 Panel testing manufactured by QIAGEN Sciences is effective and must be used for dates of service as of June 25, 2020 and after.

​

  • 0223U

 

CPT code 0225U for ePlex® Respiratory Pathogen Panel 2 developed by GenMark Diagnostics, Inc. is  effective and must be used for dates of service as of August 10, 2020 and after.

 

  • 0225U

 

CPT codes 0240U, 0241U, 87636, and 87637 for SARS-CoV-2 (COVID-19) and other respiratory pathogens' nucleic acid testing are effective and must be used for dates of service as of October 06, 2020 and after. 

 

  • 0240U
  • 0241U
  • 87636
  • 87637

 

DIAGNOSTIC ANTIGEN TESTING FOR COVID-19

 

CPT code 87426 for infectious agent antigen detection by immunoassay technique of SARS-CoV and/or SARS-CoV-2 is effective and must be used for dates of service as of June 25, 2020 and after.

 

  • 87426

 

CPT code 87811 for SARS-CoV-2 (COVID-19) antigen testing by immunoassay with direct optical observation is effective and must be used for dates of service as of October 06, 2020 and after.

 

  • 87811

 

​CPT code 87428 for SARS-CoV-2 (COVID-19) and other respiratory pathogens' antigen testing through an immunoassay technique is effective and must be used for dates of service as of November 09, 2020 and after.

 

  • 87428

FOR COVERAGE OF HCPCS CODE K1034 REFER TO THE COMPANY'S POSITION FOR DIRECT RIEMBURSEMENT TO MEMBERS FOR NON-PRESCRIPTION OVER-THE-COUNTER TESTS​

HCPCS code K1034 for provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared, one test count is effective and must be used for dates of service as of  April 04, 2022 and after.​.

 

  • K1034

ANTIBODY TESTING FOR COVID-19

 

CPT codes 86328 and 86769 for SARS-CoV-2 (COVID-19) qualitative or semiquantitative antibody testing are effective and must be used for dates of service as of April 10, 2020 and after.

 

  • 86328
  • 86769

 
CPT code 0224U for SARS-CoV-2 (COVID-19) antibody testing developed by Mt. Sinai Laboratory is effective and must be used for dates of service as of June 25, 2020 and after.

  • 0224U

 
CPT codes 86408 and 86409 for SARS-CoV-2 (COVID-19) neutralizing antibody screening and titer testing respectively are effective and must be used for dates of service as of August 10, 2020 and after. 

  • 86408
  • 86409

 

CPT code 0226U for Tru-Immune, a serological test that measures and also quantifies the neutralizing capacity of antibodies against the SARS-CoV-2, by Ethos Laboratories and GenScript® USA Inc. is effective and must be used for dates of service as of August 10, 2020 and after.

 

  • 0226U

 

CPT code 86413 for SARS-CoV-2 (COVID-19) quantitative antibody testing is effective and must be used for dates of service as of September 08, 2020 and after.

 

  • 86413 

 

SPECIMEN COLLECTION BY A HEALTHCARE PROFESSIONAL FOR COVID-19

 

HCPCS codes C9803, G2023 and G2024 or CPT code 99211 (as appropriate) for collection of SARS-CoV-2 (COVID-19) specimens, including nasopharyngeal swab (NP), oropharyngeal swabs (OP), serum, plasma, or venipuncture whole blood, are effective and must be used for dates of service as of March 1, 2020 and after. 

 

  • C9803: Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), any specimen source

     
  • G2023: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source

     
  • G2024: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by an approved laboratory on behalf of a home health agency, any specimen source
  • 99211: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional​

​Revenue code 0551 may be used by Home Health Agencies performing specimen collection for SARS-CoV-2 (COVID-19) and related respiratory pathogens' laboratory testing:

 

  • 0551: Skilled Nursing – Visit Charge

 

LABORATORY TESTING FOR COVID-19 DIFFERENTIAL DIAGNOSIS

 

  • 86603
  • 86710
  • 86756
  • 87260
  • 87275
  • 87276
  • 87279
  • 87280
  • 87301
  • 87400
  • 87420
  • 87501
  • 87502
  • 87503
  • 87631
  • 87632
  • 87633
  • 87634
  • 87804
  • 87807
  • 87809


SPECIMEN COLLECTION FOR COVID-19 DIFFERENTIAL DIAGNOSIS LABORATORY TESTING

  • S9529
  • 36400
  • 36405
  • 36406
  • 36410
  • 36415
  • 36420
  • 36425​​​

MODIFIER

CS: Cost-sharing waived for specified COVID-19 testing-related services that result in an order for, or administration of, a COVID-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in Rural Health Clinics and Federally Qualified Health Centers during the COVID-19 public health emergency​​


12/15/2022