COVID-19: Impact of the Coronavirus on Laboratory Billing: Coronavirus CPT Codes and HCPCS Codes

On March 13, 2020, the American Medical Association (“AMA”) adopted Current Procedural Terminology (“CPT”) code 87635 to be used nationwide to report laboratory testing for the 2019 novel coronavirus. See announcement, CPT® releases new coronavirus (COVID-19) code & description for testing. CPT code 87635 describes a laboratory testing procedure that involves the following work:

Description of Procedure (87635) 

Place specimens (e.g., nasopharyngeal or oropharyngeal swab, sputum, lower respiratory tract aspirate, bronchoalveolar lavage, and nasopharyngeal wash or aspirate or nasal aspirate) into specimen-transport containers. Use oligonucleotide primers and probes for detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (formally known as 2019-nCoV), and any pan-coronavirus types or subtypes if included, to identify viral gene target(s). Isolate and purify ribonucleic acid (RNA) from the specimens, followed by molecular amplification and analysis. Send the test result (positive, negative, inconclusive) to the patient’s physician or other QHP and report or refer to the appropriate public health officials, as indicated.

Although the code was adopted by the AMA effective March 13, 2020, for use as the industry standard for reporting of novel coronavirus tests across the nation, the AMA recognizes that the Centers for Medicare & Medicaid Services (“CMS”) already adopted two Healthcare Common Procedure Coding System (“HCPCS”) codes: U0001 and U0002. See the CMS announcement dated February 2, 2020, in which CMS describes these HCPCS codes as follows: HCPCS code U0001 is to be used for testing for SARS-CoV-2 by CDC testing laboratories.
HCPCS code U0002 was developed for use by non-CDC laboratory tests for SARS-CoV-2 testing.  

In its announcement, CMS indicated that the Medicare claims processing system would be able to accept these two HCPCS codes starting on April 1, 2020, for dates of service after February 4, 2020. Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates. CMS has also prepared and distributed to health care professionals a Medicare Administrative Contractor (“MAC”) COVID-19 Test Pricing sheet, effective as of March 12, 2020.

Whether you should use the HCPCS codes or the CPT code depends on the payer. Thus, the AMA notes that you should “contact your third-party payer to determine their guidelines regarding applicability for retroactive billing and reimbursement” because the use of HCPCS codes or CPT codes “is dependent upon the payer to which the claim is being submitted.” Moreover, the AMA cautions, “CPT and HCPCS codes should not both be reported on the same claim.” See The American Medical Association, CPT Assistant Special Edition, Vol. 30, 2020, available at https://www.ama-assn.org/system/files/2020-03/cpt-assistant-guide-coronavirus.pdf.

The AMA descriptors for CPT code 87635 are as follows:

The AMA describes the CPT code, gives a clinical example of the code’s use, and provides some helpful FAQs in a Special Edition of CPT Assistant.

Of note, the Special Edition of CPT Assistant describes that the difference between CPT 87635 and the existing CPT codes in the Pathology and Laboratory Section of the CPT code set for coronavirus, as follows:

Existing codes 87631, 87632, and 87633 are used for nucleic acid assays that detect multiple respiratory viruses in a multiplex reaction (i.e., single procedure with multiple results). Similarly, proprietary laboratory analyses (PLA) codes 0098U, 0099U, and 0100U are used to identify multiple types or subtypes of respiratory pathogens. In contrast, code 87635 is for the detection of SARS-CoV-2 (COVID-19) and any pan-coronavirus types or subtypes, and it can be reported with tests from multiple manufacturers using the stated technique.

Further, the AMA notes that in light of the Centers for Disease Control and Prevention’s (“CDC”) recommendation that both nasopharyngeal (“NP”) and oropharyngeal swabs from the upper respiratory system should be used for an initial diagnostic testing, laboratories performing multiple separate tests for the same virus should use modifier 59 (Distinct Procedural Service) for the second test coded with CPT 87635. However, on March 13, 2020, the CDC provided Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019, which states:

For initial diagnostic testing for COVID-19, CDC recommends collecting and testing an upper respiratory nasopharyngeal swab (NP). Collection of oropharyngeal swabs (OP) is a lower priority and if collected should be combined in the same tube as the NP. Collection of sputum should only be done for those patients with productive coughs. Induction of sputum is not recommended. Specimens should be collected as soon as possible once a PUI is identified, regardless of the time of symptom onset. Maintain proper infection control when collecting specimens.

CDC also recommends testing lower respiratory tract specimens, if available. For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended. For patients for whom it is clinically indicated (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen.

Conclusion

Laboratories performing coronavirus testing may want to delay billing because payors are likely not yet able to process claims with the new codes and take this time to develop a “cheat sheet” for billers that defines, by payor: (i) the acceptable CPT/HCPCS codes, (ii) when the payor will be able to process claims, and (iii) the relevant diagnosis codes.