Procedure code and Description
CPT 87635 – 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
CPT 87426 – Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])
CPT 87428 severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B
CPT 87811 – Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])
COVID-19 Billing Guides Updated with CPT Codes 87426 and 86413
Nevada Medicaid has updated the COVID-19 General Billing Guide and COVID-19 Community-Based Testing Billing Guide with the following new Current Procedural Terminology (CPT) codes. These codes have also been added to the Medicaid Management Information System (MMIS) and are active for billing. The Centers for Medicare &
Medicaid Services (CMS) has not established reimbursement rates; therefore, claims will suspend for payment with error code 853 (HCPCS Annual Update – suspend claims) and will be automatically reprocessed once rates have been established by CMS.
Claims for codes 87426 and 86413 that denied with error code 4032 (Procedure code not on file) may be resubmitted back to the dates indicated below.
o Note: Code 87426 is an add-on code under 87301. 87426 became effective by the American Medical Association on June 25, 2020. Claims may only be submitted back to this date.
o Note: 86413 became effective by the American Medical Association on September 8, 2020. Claims may only be submitted back to this date.
Currently, there are two existing CPT codes to report antigen testing using immunoassay technique for influenza type A or B (87400) and SARS-CoV-2 (87426). However, there is no code that describes multiplex immunoassay antigen testing for these three viral targets, ie, SARS-CoV, SARS-CoV-2 [COVID-19], and influenza virus types A and B. A code to report a multiplex viral pathogen panel using an antigen immunoassay technique would facilitate reporting SARS-CoV-2 testing, along with influenza types A and B in the differential diagnosis
The following clinical example and procedural description reflect a typical clinical situation for which this new code would be appropriately reported. Because of the early deployment and utilization of these tests, clinical indications are subject to further refinement as knowledge of the novel coronavirus evolves. The Panel will continue to review and may clarify these indications as more information becomes available.
Clinical Example (87428)
A 50-year-old female presents with fever, cough, and shortness of breath. A nasopharyngeal swab is collected for SARS CoV-2, influenza A, and influenza B antigen testing.
Description of Procedure (87428)
Place the swab and swirl it in a supplied reagent tube to disrupt and release viral nucleoprotein antigens; transfer an aliquot of that sample to the test cassette sample well; and place it in the analyzer. Report the qualitative results to the ordering health care professional.
COVID-19 Diagnostic Testing Reimbursement
The Centers for Medicare & Medicaid Services (CMS) has established two Healthcare Common Procedure Coding System (HCPCS) codes for coronavirus testing. HCPCS code U0001 is for CDC approved labs to use, and HCPCS code U0002 is for CDC non-approved labs to use when reporting SARS-CoV-2 testing.
CMS has established two new HCPCS codes for high throughput technology testing. HCPCS code U0003 and U0004 are to be used when making use of high throughput technologies, as described by CMS2020-01-R. These codes are effective on/ or after 4/14/2020. CMS has established new specimen collections codes for Clinical diagnostic laboratories billing for COVID-19 testing:
** HCPCS G2023- for specimen collection for severe acute respiratory syndrome, any specimen source and
** HCPCS G2024- for specimen collection for severe acute respiratory syndrome, from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source.
Clinical diagnostic laboratories should use these codes to identify specimen collection for COVID-19 testing, effective with item date of service on/or after March 1, 2020.
The AMA published CPT code 87635 in an effort to help report and track testing services related to SARS-CoV-2 in an effort to assist in reporting and reimbursement.
Medica’s reimbursement rates are based upon rates that were recently announced by the Centers for Medicare and Medicaid Services for COVID-19 testing. Medica will reimburse contracted and noncontracted providers for COVID-19 testing, unless otherwise specified by law. It is not considered medically necessary if a COVID-19 antibody test is to be used as part of ‘return-to-work’ programs, public health surveillance testing or any efforts not associated with disease diagnosis or treatment.
Reimbursement Rates for Coronavirus Diagnostic Testing:
** HCPCS U0001: $35.92
** HCPCS U0002: $51.33
** HCPCS U0003: $75.00 (effective date 4/14/2020)
** HCPCS U0004: $75.00 (effective date 4/14/2020)
** HCPCS U0005: $25.00 (Effective 1/1/2021)
** CPT 87635: $51.33
** HCPCS G2023: $23.46
** HCPCS G2024: $25.46
** HCPCS C9803: $24.67
Diagnosis Codes to be used for confirmed Coronavirus:
** B97.29: Other coronavirus
** B34.2: Coronavirus Infection
** U07.1: 2019 COVID acute respiratory disease
Diagnosis Codes recommended by the CDC for suspected Coronavirus exposure:
** Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out
** Z20.828: Contact with and (suspected) exposure to other viral communicable diseases
** Z11.52: Encounter for screening for COVID-19 (Effective 1/1/21)
** Z20.822: Contact with and (suspected) exposure to CIVUD-19 (Effective 1/1/21)