COVID-19: Coding and Billing Resource Guide

In an effort to mitigate the spread of the coronavirus while continuing to provide critical healthcare services, the Centers for Disease Control and Prevention (CDC) has advised healthcare organizations to explore alternatives to face-to-face encounters with patients. This recommendation, coupled with the particular needs of COVID-19 patient diagnosis and treatment, has resulted in a constantly evolving series of changes to payer-required coding and billing requirements.

ECG has summarized topics with reimbursement impact into the following categories:

• Telehealth Services
• COVID-19 Screening
• COVID-19 Treatment
• Additional Considerations & Implications

The remainder of this resource guide provides key tactical information and considerations for payer coding and billing requirements. ECG will continue to monitor relevant government and commercial payer bulletin releases, but provider organizations should always consult CMS and official payer communications when implementing new or updated coding and billing processes.

Telehealth Services

Nearly all payers are allowing reimbursement for telehealth services, regardless of COVID-19 diagnosis. While specific requirements vary by payer, telehealth visits are indicated by using the appropriate combination of place-of-service (POS) codes, CPT/HCPCS codes, and/or CPT modifiers.

• Traditional Medicare requests that telehealth claims be billed with the E&M CPT and POS codes that would be billed if the services were delivered in person, but with modifier 95 to indicate a telehealth visit.
• Some commercial payers have chosen to follow Medicare guidelines, while others have created their own.
• Of note, unique CPT codes already exist to specify telehealth visits, virtual check-ins, and e-visits, and most payers have outlined requirements specifying how they should be used. They are typically reimbursed at different levels and should not be billed in conjunction with standard E&Ms without first consulting a certified coder familiar with your organization’s payer guidelines.

In table 1, ECG has defined the primary unique identifiers your organization would be eligible to use for telehealth reimbursement; see table 2 for published unique identifier combination requirements for major national payers.

COVID-19 Screening

When COVID-19 screenings are performed, specific CPT and diagnosis codes defined throughout this section must be used. Additional non-COVID-19-related CPT codes and diagnoses could be added as appropriate, and standard sequencing logic should be applied.

Providers who are only performing the collection of the patient specimen should bill C9803 if performed in a hospital outpatient department and 99211 if performed in a physician office setting.

When billing accompanying diagnoses, providers should follow the guidance outlined in table 4.

COVID-19 Treatment

As indicated in the previous section, a specific diagnosis code (U07.1) was recently created to represent a confirmed COVID-19 diagnosis; this code became effective on April 1, 2020, and recent legislation in the CARES Act allows for a 20% increase in total Medicare MS-DRG payment when this code is present.

For all dates of service prior to April 1, 2020, a more generic diagnosis code was used (B97.29). The B97.29 code by definition cannot be placed in the primary diagnosis position as the condition that caused the admission; however, the U07.01 code can be placed in the primary position, which allows for more flexible and accurate coding. Table 5 was developed using common patient manifestations assuming COVID-19 as the principal diagnosis.

Organizations should ensure the correct diagnosis code and sequencing is used based on the patient’s date of service or discharge date. Clinicians and coders should consider the following information when coding:

• A positive test result is not required to use U07.01, as long as the clinical picture and treat-ment support a positive COVID-19 diagnosis and this is well documented in the clinician’s diagnostic statement.
• If the patient has a positive test result and this is maintained in the patient’s medical record, clinicians do not need to directly affirm COVID-19 in their documentation for use of U07.01.
• To use U07.01 as the primary diagnosis, clinicians must both affirm the COVID-19 diagnosis and link a nonpulmonary diagnosis as a manifestation of the COVID infection in their docu-mentation.

Organizations’ CDI and provider education specialists should develop communication materials for clinicians to use in optimizing coding and reimbursement.

Additional Considerations and Implications

As your organization navigates the ever-changing coding and billing requirements for COVID-19, be sure to:

• Sign up for and consistently monitor CMS briefings and other major payer bulletins to remain informed.
• Understand that all commercial payers have their own requirements that can change often. Closely coordinate with your major payers to ensure your organization is compliant with their most recently updated policies. For more information on commercial payers, see ECG’s webinar Telehealth Services: Successfully Navigating the Payer Landscape in Response to COVID-19.
• Pay special attention to effective dates, as coding and billing requirements change; when addressing denials and analyzing paid claims for appropriate reimbursement, an organized timeline will be critical to determine what action was considered appropriate at the time the service was rendered.
• Isolate and quantify telehealth and COVID-19 denials by payer. This will provide your organization insight as to whether coding and billing requirements were appropriately communicated and implemented into the system. Work rapidly with payers to escalate any trends and resolve any issues as they arise.

As the pandemic develops, coding and billing requirements will continue to evolve. Provider organizations must safeguard telehealth and COVID-19-related revenues by approaching coding and billing in a methodical and organized fashion. These developed processes will result in maximum reimbursement for provided services.