What you need to know about coronavirus (COVID-19) 

Updated 11/29/21

We are complying with CMS coding guidelines for COVID-19 testing. The CDC is a reliable source for current testing information. As with any claim submission to the Health Plan, it is important that claims for COVID-19 testing be submitted with an accurate diagnosis code.

Non-Covered

In most cases, the Health Plan does not cover COVID-19 testing when requested by a member or third party for reasons such as for employment, school admission, entertainment, or travel. Claims submitted for COVID-19 testing requested by a member or third party should include the appropriate diagnosis code from Z02.0 through Z02.9 as the primary diagnosis.

Covered

There is no copayment, coinsurance, or deductible for medically necessary COVID-19 tests when ordered by a provider during the public health emergency. Medically necessary testing includes tests for members with known or suspected symptoms or known or suspected exposure. It also includes tests for members entering a medical facility for services.

Effective October 1, 2021, the ICD-10 CM code used to report COVID-19 testing for asymptomatic and symptomatic patients with actual or suspected exposure to COVID-19 is Z20.822 – Contact with and (suspected) exposure to COVID-19. Per the ICD-10-CM Official Guidelines for Coding and Reporting, a screening code such as Z11.52 – Encounter for screening for COVID-19 is generally not appropriate during the COVID-19 pandemic.

Modifier CS

For dates of service on and after March 18, 2020, Dean Health Plan requires modifier CS when billing E&M services related to the administration of a COVID-19 test or to the evaluation of a patient for purposes of determining the need for such a test. Modifier CS will allow us to accurately waive member cost share on services related to COVID-19 testing.

Providers may submit corrected claims to include modifier CS if member cost share was applied to a service related to COVID-19 testing on a previously-processed claim.

Telemedicine billing

Telehealth service (either temporary or standard) is provided via Zoom or similar audio/visual technology Modifier:  ’95 - indicating that the service rendered was actually performed via telehealth

Place of Service:  Equal to what it would have been had the service been furnished in-person (eg, 11, 20, 21, 22)
Telehealth service (either temporary or standard) is provided via traditional method involving originating site and distant practitioner

• Modifier:  None  (Medicaid requires ‘GT - Via interactive A/V telecommunication systems)
• Place of Service : ’02’ – telehealth

 

Communication technology-based services

Communication technology-based services (CTBS) are furnished via telecommunications technology but are not considered telehealth services. Examples include telephone services (CPT 99441-99443, 98966-98968), online E/M services (99421-99423, G2061-G2063).

Because these are not considered telehealth services, a telehealth modifier is not required. The Place of Service should be ‘11’ or other applicable site of the practitioner’s normal office location.

Codes and travel allowance for specimen collection

For dates of service on and after March 1, 2020, Dean Health Plan accepts the following code for COVID-19 specimen collection:

• G2023 — Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
• 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

The laboratory technicians must personally draw the sample and collect the specimen from a homebound or nursing home patient. Enlisting a messenger service for a specimen pick up does not qualify.

A travel allowance may be provided to laboratory technicians collecting specimens for COVID-19 testing from a non-hospital inpatient or homebound patients under existing codes P9603 and P9604.

Specimen collection code for hospital outpatient clinic visit

Effective for dates of service on and after March 1, 2020, CMS established a new Level II HCPCS code for COVID-19 specimens collected during a hospital outpatient clinic visit:

• HCPCS C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source.

 

COVID-19 testing using high throughput technologies

Effective on and after March 18, 2020, COVID-19 testing that uses high throughput technologies will be paid in accordance with CMS’ recently-released guidance. A high throughput technology is defined as a platform capable of automated processing of more than two hundred specimens per day. The highly sophisticated equipment requires more intensive processes and technician training to ensure quality and warrants a change in reimbursement.

Examples of high throughput technology as of April 14, 2020, include, but are not limited to, the following technologies:

• Roche cobas 6800 System
• Roche cobas 8800 System
• Abbott m2000 System
• Hologic Panther Fusion System
• GeneXpert Infinity System
• NeuMoDx 288 Molecular

HCPCS U0003 is used to report the high throughput version of tests that would otherwise be identified with CPT 87635. HCPCS U0004 is used to report the high throughput version of tests that would otherwise be identified with U0003. Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.

To receive and administer COVID-19 vaccines and supplies, organizations or individual providers are required to enroll in a federal vaccine distribution program through state immunization programs. (The exceptions to this enrollment requirement are providers who are part of a national chain that registered directly with the Centers for Disease Control [CDC]).

Note: We recommend that providers check with their organization before enrolling as some organizations may be registered as an organization in lieu of having their individual providers enroll.

For state-specific enrollment information:

• Illinois Department of Health I-Care

• Missouri COVID-19 Vaccinator 

• Oklahoma State Department of Health Provider Enrollment 

Updated 10/27/22

WellFirst Health has released communications linked from this page regarding federal recommendations, emergency use authorizations (EUAs), approvals, and applicable Health Plan processes regarding COVID-19 vaccines and administration.

The Health Plan covers FDA EUA and approved COVID-19 vaccine administration with no member cost-sharing, per the CARES Act requirements. Claims for vaccine administration should be submitted to the Health Plan, including claims for members enrolled in a Medicare Advantage plan.

Booster dose

Novavax

On October 19, 2022, the FDA granted EUA for the Novavax COVID-19 vaccine, Adjuvanted (NVX-CoV2373), as a first booster dose to be administered at least six months after completion of primary vaccination with an authorized or approved COVID-19 vaccine to either of the following populations:

• Individuals 18 years of age and older for whom an FDA-authorized mRNA bivalent COVID-19 booster vaccine is not accessible or clinically appropriate.
• Individuals 18 years of age and older who elect to receive the Novavax COVID-19 Vaccine, Adjuvanted because they would otherwise not receive a booster dose of a COVID-19 vaccine.

The CPT code and description for administration of the Novavax COVID-19 vaccine is the following:

• 0044A — Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5 mL dosage; booster

Additionally, the Novavax vaccine follows a two-dose administration. The CPT codes for each dose’s administration are the following:

• 0041A — Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; first dose
• 0042A — Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; second dose

On August 30, 2022, the FDA amended EUAs for both Moderna’s and Pfizer-BioNTech’s bivalent vaccines, to be given as a single booster dose at least two months following primary or booster vaccination. Bivalent vaccines are intended to provide protection against the original COVID-19 strain, and have also been adapted to the Omicron variant.

Moderna

The CPT code and description for administration of the Moderna bivalent booster for individuals 18 years or older is the following:

• 0134A—Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, booster dose.

 

Pfizer-BioNTech

The CPT code and description for administration of the Pfizer-BioNTech bivalent booster for individuals 12 years or older is the following:

• 0124A—Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, booster dose.

See our April 13, 2022, provider communication regarding a second COVID-19 booster shot for certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least four months ago.

See our Nov. 29, 2021, provider communication regarding booster and third dose vaccine information.

Effective Nov. 19, 2021, The FDA expanded EUA to include COVID-19 booster shots for all adults who received either the Moderna or Pfizer-BioNTech COVID-19 vaccine at least six months ago.

The Johnson and Johnson COVID-19 vaccine booster was authorized to be administered at least two months after completion of the single-dose primary regimen to individuals 18 years of age and older. Providers should use the applicable current procedural terminology (CPT) code on claims for booster dose vaccine administration, listed below.

• Pfizer-BioNTech; 0004A

• Moderna; 0064A

• Janssen; 0034A

On Oct. 20, 2021, the FDA amended EUAs for Moderna and Pfizer-BioNTech COVID-19 vaccines to allow for a single booster dose to specific populations to be administered at least six months after completion of the primary vaccination regimen.

• 65 years of age and older

• 18 through 64 years of age at high risk of severe COVID-19

• 18 through 64 years of age with frequent institutional or occupational exposure to SARS-CoV-2

Additionally, the FDA authorized the use of a heterologous (or “mix and match”) booster dose with currently available (i.e., FDA-authorized or approved) COVID-19 vaccines.

Third dose
See our Aug. 30, 2021, COVID-19 communication regarding the FDA amended EUAs for both the Pfizer-BioNTech and the Moderna COVID-19 vaccines to allow a third dose to immunocompromised individuals on Aug. 12, 2021. Use the following CPT codes for a third dose vaccine administration:

• Pfizer-BioNTech; 0003A

• Moderna; 0013A

In-home administration
See our August 5, 2021, COVID-19 communication regarding in-home COVID-19 vaccine administration. Use HCPCS code M0201 for in-home COVID-19 vaccine administration.

Vaccine EUAs and approvals for adults
See our Aug. 30, 2021, communication regarding the FDA full approval of the Pfizer-BioNTech COVID-19 vaccine for individuals 16 years of age and older on Aug. 23, 2021.

See our March 18, 2021, communication regarding the FDA EUA for the single-dose Janssen (Johnson & Johnson) COVID-19 vaccine on Feb. 27, 2021.

See our November 24, 2020, communication regarding the FDA issued EUAs for the Pfizer-BioNTech COVID-19 vaccine on December 11, 2020, and the Moderna COVID-19 vaccine on December 18, 2020.

Vaccine EUAs for children

On October 12, 2022, the FDA expanded the use of Moderna’s and Pfizer-BioNTech’s bivalent vaccines to children.

Moderna
The CPT code and description for administration of the Moderna bivalent booster for individuals 6 through 11 years is the following:

• 0144A — Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, booster dose

Pfizer-BioNTech
The CPT code and description for administration of the Pfizer-BioNTech bivalent booster for individuals 5 through 11 years is the following:

• 0154A — Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose

See our Nov. 29, 2021, provider communication regarding COVID-19 vaccines for children.

On Oct. 29, 2021, the FDA issued EUA for the Pfizer-BioNTech COVID-19 vaccine for children 5 through 11 years of age.

This is to be administered as a two-dose primary series, three weeks apart, at a lower dose (10 micrograms) than that used for individuals 12 years of age and older (30 micrograms).

Providers should use the applicable CPT code on claims specific to the first or second dose vaccine administration, listed below.

• Pfizer-BioNTech; 0071A - 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, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose

• Pfizer-BioNTech; 0072A - Second dose

Booster
On Jan. 3, 2022, the FDA amended the EUA for the Pfizer-BioNTech COVID-19 vaccine to expand the use of a single booster dose to include individuals 12 through 15 years of age.

Additionally, the EUA shortens the time between the completion of the primary Pfizer-BioNTech COVID-19 vaccination and a booster dose to at least five months and allows for a third primary series dose for certain immunocompromised children 5 through 11 years of age.

EVUSHELD
The FDA issued EUA for AstraZeneca’s EVUSHELD (tixagevimab co-packaged with cilgavimab) for the pre-exposure prophylaxis (prevention) of COVID-19 in certain adults and pediatric patients (12 years of age and older weighing at least 88 pounds).

EVUSHELD is intended for the highest risk immunocompromised individuals who are not expected to have an effective response to vaccination. EVUSHELD is indicated for pre-exposure prophylaxis only and not for treatment of patients with COVID-19. It is not intended as a replacement for COVID-19 vaccines or boosters.

Updated 10/27/22

Throughout the COVID-19 pandemic, the FDA has revised authorizations for monoclonal antibody treatments as the virus has evolved.

Effective Jan. 1, 2022, claims for the administration of COVID-19 vaccines and monoclonal antibody products to members enrolled in a Medicare Advantage plan must be submitted to the Health Plan.

Updated 6/14/21

As  the public health emergency stabilizes, the Health Plan is determining appropriate timing for resumption of pre-COVID-19 operations.

Waiving authorizations

Outpatient services

WellFirst Health is waiving authorization requirements for outpatient services directly for and related to COVID-19. Providers must bill for these services using the COVID-19 ICD-10 codes to appropriately bypass authorization requirements for services that qualify for the waiver.

Antibody testing

WellFirst Health does not require prior authorization for antibody testing; however, we do expect that all antibody tests be physician-ordered. Because of the variety of testing options available on the market currently, we encourage providers to know the efficacy of the antibody tests they are ordering.

Postponing elective surgeries and non-essential procedures
On March 18, 2020, CMS released a recommendation that all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the COVID-19 outbreak for the preservation of personal protective equipment, beds, and ventilators. In response, Utilization Management is evaluating all approved prior authorizations on file for elective inpatient admissions with a surgery/admit date on or before March 16, 2020, to determine if the surgery was rendered:

• If the surgery has been performed, we will process the applicable provider claims using our standard process.
• If the surgery was not performed, we will change the admit/start date on the prior authorization to a future date. We will continue to do so, as necessary, during the COVID-19 public health emergency. Authorizations with a changed start/admit date will be denoted by a COVID-19 statement in the Provider Portal authorization summary.

    
Providers do not need to obtain a new prior authorization for any already-approved surgeries. Once CMS lifts its recommendation and the surgery is scheduled, providers will need to call our Customer Care Center to report the date of surgery, as required by our current process.

Providers who are not equipped to handle COVID-19 patient inquiries or collect specimens for testing can contact us for the nearest in-network provider at DHP.PNCInquiry@deancare.com.

Providers who do not have access to a qualifying laboratory for COVID-19 testing can contact one of the following in-network FDA-approved laboratories:

• The State Lab

• Quest Diagnostics

• LabCorp

Updated 2/23/22

We are referring to the CMS Medicare Telemedicine Health Care Provider Fact Sheet for our telemedicine coverage guidance  Our expanded coverage will remain in effect until further notice.

To support needed provider network adequacy, protect members and providers, and promote access to care, we are offering Zoom meeting licensure to providers without the ability to conduct telemedicine services during the COVID-19 public health emergency. Providers may contact their Provider Network Consultant if they are interested in obtaining a Zoom license to provide telehealth services.

To accommodate Medicare beneficiaries who don’t have access to or are hesitant to use the interactive audio-video technology required for telehealth services, the Centers for Medicare & Medicaid (CMS) is waiving the video requirement for certain telehealth services. WellFirst Health is adopting this waiver for all products during the public health emergency to allow members to receive these services via telephone (audio-only). The services that can be rendered via telephone have been added to CMS’s List of Medicare Telehealth Services .

Because practitioners are providing audio-only services in instances that would have been provided as in-person or telehealth visit under non-COVID-19 circumstances, CMS established new Relative Value Units (RVUs) for audio-only assessment and management services. The RVUs are based on crosswalks to the most analogous office/outpatient evaluation and management (E&M) services resulting in increased reimbursement for CPT codes 99441, 99442, and 99443. 

Place of service codes for telehealth
Effective Jan. 1, 2022, the description for POS 02 changed to distinguish that the patient is not located in their home when receiving health services or health related services through telecommunication technology.

• New description for POS 02 – Telehealth provided other than in patient’s home (replaced old description of POS 02 – Telehealth)

Additionally, a new POS code 10 has been created.

• New POS 10 – Telehealth Provided in Patient’s Home

POS codes for commercial plans
On claims for members in a commercial benefit plan, providers may submit POS 10 or a POS code equal to what it would have been had the service been furnished in-person (e.g., 11, 20, 21, 22).
Regardless of what POS code is used on a commercial claim for telehealth, a telehealth modifier is also required.

• 93 – Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system
  • Effective Jan. 1, 2022, modifier 93 should be used for audio-only visits.
• 95 - Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system

POS codes for Medicare Advantage
CMS does not require telehealth POS codes 02 and 10 on Medicare claims during the public health emergency and instructs their providers to continue billing according to current applicable rules. While POS 10 will be accepted on Medicare claims, CMS has advised that these claims will be processed and reimbursed as if POS 02 was billed which is typically a lower rate.

Refer to the CMS MLN Matters article, number MM12427, titled “New/Modifications to the Place of Service (POS) Codes for Telehealth,” for more information.

Telehealth services through 2023
CMS has extended some telehealth services, that were added on a temporary basis in response to the public health emergency, to remain in place through 2023. Refer to the CMS MLN Matters article, number MM 12549, titled “CY2022 Telehealth Update Medicare Physician Fee Schedule," for more information.

Communication technology-based services
Communication technology-based services (CTBS) are furnished via telecommunications technology but are not considered telehealth services. Our coverage of CTBS services includes:

Telephone Services (for all health plan products)

• 99441, 99442, and 99443 (telephone services) 
• 98966, 98967, 98968 (telephone services by qualified non-physician providers) 

Online evaluation and management or assessment and management

• 99421, 99421, 99423 (Online digital evaluation and management service)
• G2061, G2062, G2063 (online assessment and management, by qualified non-physician providers)

Evaluation of recorded video/image and virtual check in.

• G2010 (remote evaluation of recorded video or image)
• G2012 (Brief communication technology-based service, e.g., virtual check-in)

During this public health emergency, Medicare is relaxing rules for HCPCS G2010 and G2012 to include practitioners such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists. Services described in G2010 and G2012 are considered “sometimes therapy” services and would require a GN, GO, or GP modifier when furnished by the private practice occupational therapist, physical therapist, and speech-language pathologist.

CMS has also clarified that several types of practitioners are already allowed to bill procedure codes G2061, G2062, and G2063. These include licensed clinical social worker services, clinical psychologist services, physical therapist services, occupational therapist services, or speech language pathologist services.

These services may temporarily be furnished to both new and established patients. Member consent to receive these services must be received, but can be documented by Auxiliary staff under general supervision.

Providers should continue to only bill codes that are on their fee schedules. If you need assistance verifying the codes on your fee schedule or have specific questions on allowable codes other than those listed within our guidelines, contact your Provider Network Consultant.