COVID-19: Billing, coding and credentialing

Last updated: Feb. 2, 2022

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 through Sept. 30, 2021. 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 condition code 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. We only cover one COVID-19 test per day.

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-related services

Effective dates along with all known current and past reimbursement amounts are available in our fee schedules.

Codes without posted rates may not be covered. We continue to update codes and reimbursement as new information is available.

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

U0001 and U0002, see the CMS FAQ
U0003 and U0004, see the CMS ruling
87635, see the AMA's website

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.

Frequently asked questions

Can antibody tests provided by RNs and LPNs be covered as medically necessary?

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.

Is antibody testing covered when a patient is receiving it to determine if they can donate plasma?

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.

Is antibody testing covered when a patient is asymptomatic but receiving the test prior to surgery?

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.

I see the reimbursement rate for some COVID-19 lab test codes are TBD. Why is that?

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.

If the diagnosis code Z11.59 is used will the test be covered by the member's plan? Does this code mean the test was medically necessary?

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.

How is Priority Health defining medical necessity?

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

What's the difference between code Z03.818 "Encounter for observation for suspected exposure to other biological agents ruled out" and code Z20.818, "Contact with and (suspected) exposure to other viral communicable diseases" in relation to COVID-19?

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.

Are "back to school" COVID-19 tests covered for children who are asymptomatic, when not medically necessary?

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.

Is antibody testing covered for asymptomatic patients or those who need a test to return to work?

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.

If a COVID-19 lab test is ordered for pre-procedural testing, should I use diagnosis code Z11.59 "Encounter for screening for other viral disease"?

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.

When do I use the CS vs the SC modifer?

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.

Why is the SC modifier required for some diagnosis codes?