Medical Coding & Billing Guidelines and Tips for COVID-19
The COVID-19 pandemic has created unique challenges for medical coders and billers. As the healthcare industry continues to navigate the complexities of treating COVID-19 patients, there have been significant changes in coding and billing procedures. These changes reflect the dynamic nature of the virus and its impact on healthcare systems. Understanding the latest guidelines, tips, and best practices is critical for accurate reimbursement, compliance, and optimal care delivery.
Key Coding Changes for COVID-19
Medical coders must stay updated on the constantly evolving COVID-19-related codes. The Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), and other entities have issued guidance to help coders stay on track.
ICD-10-CM Diagnosis Codes:
- U07.1 – COVID-19: The primary diagnosis code for confirmed COVID-19 cases, including patients who test positive or show symptoms consistent with COVID-19.
- Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases: For patients who have been exposed but are asymptomatic or awaiting test results.
- Z11.59 – Encounter for screening for other viral diseases: Used for preventive screenings related to COVID-19, such as routine testing.
ICD-10-PCS Procedure Codes:
- COVID-19 testing procedures are commonly billed using CPT codes 87635 (for PCR tests) and CPT code 87426 (for antigen tests).
- Additional codes for the administration of COVID-19 vaccines (e.g., CPT codes 91300 for Pfizer/BioNTech, CPT code 91301 for Moderna) have also been added.
ICD-10-CM Codes for Post-COVID-19 Conditions:
There are specific codes for conditions that may arise after COVID-19 infection:
- J12.82 – Pneumonia due to COVID-19
- M35.81 – Multisystem inflammatory syndrome
- R11.2 – Nausea with vomiting
- R63.5 – Abnormal weight loss
COVID-19 Testing and Vaccination Codes
COVID-19 testing is an essential part of managing the pandemic, and medical coders must ensure accurate coding of testing services. When reporting COVID-19 tests, make sure to use the appropriate CPT codes to describe the test type (e.g., molecular or antigen tests).
- CPT code 87635 is used for SARS-CoV-2 PCR testing.
- CPT codes 87426 and 87811 may be used for antigen testing.
Vaccines have their own set of codes. The CPT codes 91300 (Pfizer-BioNTech) and CPT code 91301 (Moderna) should be used for the vaccines, alongside specific administration codes for the vaccination procedure (e.g., CPT code 0001A for the first dose of the Pfizer vaccine).
Telemedicine & Virtual Care Billing
Due to COVID-19, telemedicine has become more widely used as a method for healthcare delivery. As of now, telehealth services are reimbursable under various payer systems, but it’s important to follow correct coding practices to ensure reimbursement.
CPT Codes for Telehealth:
- 99441-99443 – Telephone consultations for non-face-to-face services.
- 99201-99215 – Office and outpatient E/M services, which can be used for telehealth visits.
Remember to check payer-specific requirements as some insurers may have unique billing rules regarding telemedicine and virtual care, especially during the pandemic.
Telehealth https://codingclarified.com/telehealth/
COVID-19-Related Hospital & Inpatient Billing
Hospitals and inpatient providers must use the correct diagnostic and procedural codes when billing for COVID-19-related services, including treatments and care.
- Critical Care and Ventilation Services: These services require detailed coding using specific CPT and ICD-10-PCS codes.
- For example, CPT code 31500 for intubation and CPT code 99291 for critical care.
- Hospital Stay: For patients admitted with COVID-19, bill with ICD-10 codes for COVID-19 diagnosis, and include appropriate CPT or HCPCS codes to report additional procedures like mechanical ventilation or ICU stays.
Medicare Specific Guidelines:
- Under the COVID-19 Public Health Emergency (PHE), Medicare allows for greater flexibility in billing, including for telehealth services, which should be reported using the appropriate G codes.
- Hospital Readmissions: Pay special attention to the rules around readmission for COVID-19 patients, as some may face additional scrutiny, particularly for potential re-infection or complications.
Modifiers for COVID-19 Billing
- Modifier CS: This modifier is used to indicate that a service was provided during the COVID-19 public health emergency and was eligible for cost-sharing waivers under Medicare and Medicaid.
- Modifier CR: For services impacted by the COVID-19 emergency declaration, such as those delivered under temporary waivers or emergency measures.
CPT Modifiers https://codingclarified.com/cpt-medical-modifiers/
Billing for COVID-19 Related Services
Co-Pay Waivers: Many insurers, including Medicare and Medicaid, have waived patient co-pays for COVID-19 testing, vaccinations, and related services. Ensure that when billing these services, co-pays are appropriately waived or billed per the payer’s requirements.
Medicare Waivers for Emergency Services: There are specific billing procedures for services provided under Medicare’s emergency waivers, such as extended coverage for certain outpatient services or hospital services that are normally limited.
Documentation Best Practices
Accurate and thorough documentation is essential for ensuring that COVID-19-related claims are reimbursed correctly.
- Include specific details about COVID-19 testing, diagnosis, treatment, and any complications.
- For telehealth, make sure to document the modality of communication, the type of service provided, and the patient’s consent for telehealth services.
- Ensure that codes reflect the exact services provided, such as intubation, ventilation, ICU care, or other interventions.
Common Billing Mistakes to Avoid
- Incorrect Coding of COVID-19 Testing and Vaccination: Use the correct CPT and ICD-10 codes for COVID-19 testing and vaccination to avoid denials.
- Not Using the Correct Modifiers: Ensure that you use modifiers like CS or CR when required.
- Failure to Document Properly: Missing or vague documentation may lead to denials or delays in payment.
- Incorrect Use of Telehealth Codes: Be careful when billing for telehealth services to ensure you use the proper CPT or HCPCS codes, especially during the emergency period.
Resources for Keeping Up-to-Date
The coding landscape for COVID-19 continues to change, and it’s crucial to stay updated with resources like:
- Centers for Medicare & Medicaid Services (CMS)
- American Medical Association (AMA)
- American Health Information Management Association (AHIMA)
- The Centers for Disease Control and Prevention (CDC)
- American Academy of Professional Coders (AAPC)
The impact of COVID-19 on the healthcare industry has necessitated numerous updates to coding and billing practices. Medical coders and billers must ensure they are following the latest guidelines for accurate coding, avoid common errors, and stay compliant with payer requirements. By staying updated and adhering to these practices, healthcare providers can ensure proper reimbursement and continue delivering high-quality care in these challenging times
Coding for COVID-19 Vaccine Shots https://www.cms.gov/medicare/payment/covid-19/coding-covid-19-vaccine-shots#:~:text=The%20COVID%2D19%20public%20health%20emergency%20(PHE)%20ended,COVID%2D19%20vaccines%20during%20and%20after%20the%20PHE.