Coding COVID for Uninsured Patients

Written by: AIHC Blogger

This article is to communicate information from the Health Resources & Services Administration (HRSA) regarding the coding of COVID-19 claims for uninsured patients. This information is not consulting or legal advice and is provided as a summary for educational purposes only.

Health care providers who have conducted COVID-19 testing or provided treatment for uninsured individuals with a COVID-19 primary diagnosis on or after February 4, 2020, or provided COVID-19 vaccine administration to uninsured individuals can electronically request claims reimbursement through the program and will be reimbursed generally at Medicare rates, subject to available funding.

Steps involve: enrolling as a provider participant, checking patient eligibility, submitting patient information, submitting claims electronically, and receiving payment via direct deposit.

A separate program, the HRSA COVID-19 Coverage Assistance Fund, is available to reimburse providers for COVID-19 vaccine administration to underinsured individuals whose health plan either does not include COVID-19 vaccination as a covered benefit or covers COVID-19 vaccine administration but with cost-sharing.

Who Is Eligible?

Providers may submit claims for uninsured individuals in the U.S. without health care coverage.   Providers will verify and attest that the patient does not have individual, employer-sponsored, Medicare or Medicaid coverage, and no other payer will reimburse them for COVID-19 testing, treatment for COVID-19, and/or COVID-19 vaccine administration for that patient.

Testing Codes - Hospitals (Including Hospital Labs) and Physicians

For diagnostic testing and testing-related services to be eligible for reimbursement, claims submitted for testing-related visits rendered in an office, urgent care or emergency room, or via telehealth setting must include one of the following ICD-10-CM diagnosis codes:

For antibody testing and testing-related services to be eligible for reimbursement, claims submitted for testing-related visits rendered in an office, urgent care or emergency room, or via telehealth setting must include one of the following procedure codes:

Testing Codes - Independent Labs

Claim reimbursement eligibility for diagnostic testing services performed by independent labs is different than claim reimbursement eligibility for such services performed by hospitals (including hospital labs) or physicians. This is because independent labs do not always know the reason for testing when ordered by another provider and they are dependent on the diagnosis information indicated by the provider. Therefore, HRSA will reimburse for specific COVID-19 diagnostic testing services (individual procedure codes) for any diagnosis only when performed by independent labs.

For testing to be eligible for reimbursement billed by an independent lab, claims submitted must include one of the following diagnosis codes:

As an exception to the above requirement, single line-item claims for the following procedure codes with any diagnosis will also be eligible for reimbursement:

• COVID-19 tests: U0001, U0002, U0003, U0004, 87635, 87426, 87428, 87636, 87637, 87811, 0225U, 0226U, 0240U, 0241U
• Antibody tests: 86318, 86328, 86769
• Specimen collection: G2023, G2024 [must utilize the appropriate POS related to a Skilled Nursing Facility (SNF) or Home Health Agency (HHA)]

Vaccination Codes

Claims submitted for the administration of an FDA-licensed or authorized vaccine must be submitted as single line-item claims*, and must include one of the following codes to be eligible for reimbursement:

• Pfizer: 0001A, 0002A, 0003A, 0004A, 0071A, 0072A
• Moderna: 0011A, 0012A, 0013A, 0064A
• Janssen: 0031A, 0034A

Only the administration of the vaccine is eligible for reimbursement, not the vaccine/serum itself.

For guidance on eligibility and billing for vaccine administration, refer to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) websites.

Effective for dates of service on or after July 1, 2021: Dental providers should no longer submit claims with codes D1701–D1704 or D1707. Only the medical vaccine administration codes listed above should be used.

* Exceptions to single-line claims:

• Additional doses of the COVID-19 vaccine for the same patient on different dates of service will be accepted.
• Federally Qualified Health Centers (FQHCs) should follow their standard billing requirements, submitting an Evaluation and Management code along with the vaccine administration code.
• In-home vaccine administration will require submitting an additional line with relevant code M0201.

Historical HRSA Guidance

The HRSA COVID-19 Uninsured Program adheres to guidance set forth in the Medicare Claims Processing Manual, Chapter 26, as it relates to the use of place of service codes.

For dates of service or discharges on or after April 1, 2020, providers will use primary diagnosis U07.1 to indicate COVID-19 is the primary reason for treatment except for pregnancy for which providers will use O98.5- as primary diagnosis and U07.1 as the secondary diagnosis.

For dates of services or discharges prior to April 1, 2020, there is no equivalent diagnosis to indicate COVID-19 is the primary reason for treatment. To address this issue, HRSA established separate guidance for this program to use B97.29 as the primary diagnosis when COVID-19 is the primary reason for treatment except for pregnancy for which providers would use O98.5- as the primary diagnosis and B97.29 as the secondary diagnosis (similar to how U07.1 is used).

CMS released guidance (PDF) indicating pricing can occur when B97.29 is included in any position on the claim, including primary, for dates of service before April 1, 2020. Given this guidance, services or discharges prior to April 1, 2020, will be eligible for reimbursement from the HRSA COVID-19 Claims Reimbursement program if the primary diagnosis is B97.29 OR if the primary diagnosis is pregnancy O98.5- and the secondary diagnosis is B97.29.

HRSA recognizes that the use of B97.29 as the primary diagnosis as described above is different from the ICD-10-CM Official Coding Guidelines – Supplement for Coding encounters related to COVID-19 Coronavirus Outbreak.

HRSA is not providing coding guidance to providers. Rather, HRSA is providing billing guidance to allow providers to identify and submit only claims eligible for reimbursement under this program, which is exclusively for reimbursing providers for COVID-19 testing of uninsured individuals and for treatment for uninsured individuals when COVID-19 is the primary reason for treatment, except as noted.