COVID-19: Billing, coding and credentialing

Last updated: Jan. 13, 2021

COVID-19 vaccine billing and reimbursement 

See our COVID-19 vaccine billing and reimbursement page for more information.

Coding for COVID-19 diagnoses

If the primary treatment you're providing is for COVID-19, make sure to report COVID-19 as the primary diagnosis. Use ICD-10 code U07.1 for dates of service Apr. 1, 2020 and after, or use B9729 for dates of service from March 11 - March 31, 2020. Your patients will have a $0 cost share for treatment when COVID-19 is the primary diagnosis though Dec. 31, 2020. Per ICD-10 coding guidelines, use additional codes to identify pneumonia or other manifestations.

For services prior to Apr. 1, conditions confirmed due to (or associated with) COVID-19, such as pneumonia, acute bronchitis, lower respiratory infection and ARDS, are coded with B97.29 (other coronavirus as the cause of diseases classified elsewhere). Note that diagnosis code B34.2, Coronavirus infection, unspecified, would in general not be appropriate for COVID-19 because the cases have universally been respiratory in nature, so the site would not be "unspecified."

Coding for services that result in COVID-19 testing

Provider offices, urgent care and emergency rooms: Anytime an E&M visit results in COVID-19 test being ordered, you must add modifier CS or CR. Both identify the service as being related to COVID-19.

If you have claims that resulted in the ordering of a COVID-19 test and they denied or were processed with member liability, you should rebill claims using a CR or CS modifier dating back to February 4, 2020. This modifier should not be added to services billed for treatment of COVID-19, such as labs and x-rays. Facilities: If a hospital visit results in a COVID-19 test being ordered due to a patient's symptoms, also use condition code DR. The DR modifier should not be used for tests ordered for asymptomatic patients as part of pre-procedural testing or prior to performing other outpatient services per hospital protocol.

Coding for COVID-19 testing, including antibody

Testing for COVID-19, including antibody testing, is only covered with no member cost-share when it's medically necessary. The test must be ordered by a physician or advanced practice provider (APP), a physician assistant or nurse practitioner.

Updated June 2020 to reduce how often the SC modifier is needed.

When you order a COVID-19 test, whether molecular or serologic/antibody:

  • For most diagnoses, the SC modifier is not necessary to indicate that the test was medically necessary
  • The SC modifier must be added for select codes that are generic or typically unrelated. See the complete list.
  • Some diagnoses will always deny for member liability. If COVID-19 lab test is billed with these diagnoses, regardless of additional diagnoses billed or if the SC modifier is added, the claim will deny. See the complete list.

Make sure to keep medical necessity documentation. We reserve the right to audit for medical necessity.

Coding and payments for COVID-19 lab tests

To report lab testing services that diagnose the presence of the novel coronavirus, use the following codes. For more information:

We're not currently reimbursing for codes 86408, 86409, 86413, 99072, 0223U, 0224U, U225U and 0226U. This is because rates for these codes have not been released by CMS or the State of Michigan. Codes without posted rates may not be covered. We'll update the codes once we have rate and coverage information. 

  Medicare Commercial Medicaid

U0001

For CDC's 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel for dates of service Feb. 4, 2020 and after

 $35.92 $35.92 $29.74

U0002

2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC

 $51.31 $51.31 $42.48

U0003

To identify tests that would otherwise be identified by CPT code 87635 but are performed with high throughput technology

 $75 $75 $75

U0004

To identify tests that would otherwise be identified by U0002 but are performed with high throughput technology

 $75 $75 $75

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 two calendar days from date and time of specimen collection

 $25 $25 $25  

0001A

Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose 

 TBD $16.94 TBD  

0002A

Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose

 TBD $28.39 TBD  

0011A

Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose

 TBD $16.94 TBD  

0012A

Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose

 TBD $28.39 TBD  

36415

Blood draw for antibody testing (Note: 99000: Handling/conveying of the specimen is not separately payable).

 $3.00 See our fee schedule $2.70

86328

Immunoassay for infectious agent antibody(ies), qualitative or semiqualitative, single step method (eg regent strip)

 $45.23 $45.23 $37.45

86408

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen

 TBD $42.22 TBD  

86409

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer

 TBD $105.38 TBD  

86413

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronoavirus disease [COVID-19]) antibody, quantitative

 $51.43 $51.43 TBD  

86769

Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

 $42.13 $42.13 $34.88

87426

Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndromecoronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])

 $35.33 $35.33 $37.45  

87428

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]) and influenza virus types A and B

 TBD $35.33 TBD  

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

 $51.31 $51.31 $42.48

87636

Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique

 TBD $142.63 TBD  

87637

Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique

 TBD $142.63 TBD  

87811

Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease

 TBD $41.38 TBD  

C9803

Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source retroactive to March 1, 2020

 $23.00 $23.00 N/A

91300

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use  

 $0 $0 $0  

91301

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use 

$0 $0 $0  

99072

Additional supplies, materials and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory transmitted infectious disease. 

 Not separately payable Not separately payable Not separately payable  

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. If specimen collection happens at the physician’s office, you can report 99211.

See our fee schedule See our fee schedule See our fee schedule  

G2023

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

 $23.46 $23.46 N/A

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 a laboratory on behalf of a home health agency, any specimen source

 $25.46 $25.46 N/A

0224U

Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV- 2) (Coronavirus disease [COVID-19]), includes titer(s), when performed

 TBD $42.22 TBD  

0226U

Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum

 TBD $42.22 TBD  

0240U

Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected

 TBD $142.63 TBD  

0241U

Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected

 TBD $142.63 TBD  

M0239

Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

 $309.60 $309.60 TBD  

 M0243

Intravenous infusion, casirvimab and imdevimab, includes infusion and post administration monitoring

 $309.60 $309.60 TBD  

The Michigan Department of Health and Human Services (MDHHS) advises you complete the Human Infection with 2019 Novel Coronavirus Person Under Investigation (PUI) and Case Report Form if a patient tests positive for COVID-19. 

Credentialing providers quickly

If you're a new provider who needs to be credentialed with us to meet demands for capacity during COVID-19, complete our Provider Information Form and be sure to check "yes" on the COVID-19 question at the top.

For more information, see our Disaster Credentialing process within the Practitioner Credentialing Overview policy.

Behavioral health providers: There's no change to your credentialing process. See behavioral health credentialing for more details.

Moving providers to different locations

Participating providers can treat our members at different locations under a different tax ID. You will be reimbursed at your current rates. Your patient may have different out-of-pocket costs depending on their benefits.

To make temporary changes to a provider’s location and tax ID:

Do not hold your claims. Submit claims with the location and tax ID where the service was provided. We'll process claims using the temporary location through September 30, 2020. 

If you have permanent changes, follow our normal provider change process.

Collecting copays from Medicare Advantage members for primary care services

Medicare Advantage members will have no cost share for in-person and telehealth primary care services May 1 - Dec. 31, 2020. Because we're waiving cost-sharing for these members, providers should not collect copays for these services. Providers will still be reimbursed the full contracted amount for these services.

Learn more about how we're providing financial support to members and providers in response to COVID-19.

Frequently asked questions

Per State of Michigan orders, testing can be requested and provided by a variety of parties. The determination of medical necessity can be made by physicians.

No, infectious disease testing on a specimen for the purpose of routine plasma donation is not covered per plan documents. COVID-19 antibody testing on plasma for the purpose of COVID-19 convalescent plasma donation is not covered.

Yes, if the physician determines it is medically necessary for a patient to be tested prior to surgery and codes the test using the SC modifier, it would be covered.

We're not currently reimbursing for codes 86408, 86409, 0223U, 0224U, U225U and 0226U. This is because rates for these codes have not been released by CMS or the State of Michigan. If a rate is published, we will retroactively pay claims for these codes.

Diagnosis code Z11.59, "Encounter for screening for other viral disease” is used when a patient is tested for a virus, such as COVID-19, with no known exposure to the virus, and the test results come back as negative for COVID-19 or unknown. Without the use of the SC modifier, this diagnosis code would result in the patient having their normal cost share for testing and treatment.

Medical necessity is determined by the ordering physician and is defined in provider contracts.

Code Z03.818 should be used if a patient is asymptomatic and there is a possible exposure to COVID-19 and the patient tests negative for COVID-19. 

Code Z20.828 should be used if a patient has a known or suspected exposure to COVID- 19, is exhibiting signs/symptoms associated with COVID-19, and the test results are negative, inconclusive, or unknown. 

See the CDC’s website or the Journal of the America Health Information Management Association for more information.

For a COVID-19 lab test to be covered by the member’s plan with no copay, deductibles or coinsurance, it must be medically necessary. We do not cover tests as a condition of employment or returning to work or school.

No. Priority Health does not cover tests that are required only as a condition of employment. This includes drug tests and antibody testing for viruses like COVID-19. A provider must request the test for medically necessary reasons.

For routine pre-procedural or pre-operative testing, including COVID-19 labs, we would expect to see diagnosis code Z01.812 "Encounter for pre-procedural laboratory examination" reported for these services.

The CS modifier indicates that an E&M visit resulted in a COVID-19 test being ordered. For most diagnoses, the SC modifier is not necessary to indicate that the test was medically necessary. The SC modifier must be added for select codes that are generic or typically unrelated. Some diagnoses will always deny for member liability.

See the complete list.

For a COVID-19 lab test to be covered by the member’s plan with no copay, deductibles or coinsurance, it must be medically necessary. We do not cover tests as a condition of employment or returning to work. Using the SC modifier helps us understand that the test was medically necessary.