CurrentFlorida BluePolicy N/A

COVID-19 Provider Billing Guidelines

Billing and coverage guidance for COVID-19 related testing, office visits, virtual visits, and related services for Florida Blue lines of business and providers submitting claims.

Policy Summary

PayerFlorida Blue

PolicyCOVID-19 Provider Billing Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date03/15/2020

Next Review DateN/A

Key ActionSubmit claims using the guidelines; claims must meet accepted standard of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0$member cost share for FDA-approved molecular/antigen COVID-19 tests

0$member cost share for FDA-approved serology/antibody COVID-19 tests

03/15/2020effective date referenced for serology tests and virtual visit coverage

08/31/2021noted expiration date for some COVID-19 cost-share waivers

U0002, U0003, U0004listed molecular/antigen sample codes

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Coverage Criteria for COVID-19 Testing and Related Services

inv-01: Molecular/Antigen tests

Covered when ALL of the following are met:

FDA‑approved molecular or antigen laboratory test for SARS‑CoV‑2.

Test billed using an eligible CPT/HCPCS code (examples listed in policy: U0002, U0003, U0004, 87426, 87428, 87635, 87811, 87636, 87637, 0240U, 0241U, G2023, G2024, 0202U).

Service performed by an eligible provider and place of service (Hospital, Laboratory; Off‑Campus Outpatient Hospital (19), On‑Campus Outpatient Hospital (22), Independent Laboratory (81), Office (11), Pharmacy (01), Independent Clinic (49), Public Health Clinic (49)).

Applicable to participating and non‑participating providers per member contract; applies to stated lines of business (see policy).

inv-02: Serology/Antibody tests

Covered when ALL of the following are met:

FDA‑approved serology/antibody laboratory test for SARS‑CoV‑2.

Test billed using an eligible CPT/HCPCS code (examples listed in policy: 86328, 86408, 86409, 86413, 86769, 0224U, 0226U; HCPCS C9803).

Service performed by an eligible provider and place of service (Hospital, Laboratory; Off‑Campus Outpatient Hospital (19), On‑Campus Outpatient Hospital (22), Independent Laboratory (81), Pharmacy (01), Independent Clinic (49), Public Health Clinic (49)).

Applicable to participating and non‑participating providers per member contract; effective date 03/15/2020; applies to listed lines of business (see policy).

inv-03: Office visits tied to testing

Covered when ALL of the following are met:

Office visit or related service results in an order for a COVID‑19 test.

Visit is billed with an appropriate diagnosis code for testing (examples listed: B97.29, Z03.818, Z20.822, Z20.828, U07.1).

Where specimen collection is billed separately, use applicable procedure codes (99000, 99001) as applicable per policy guidance.

Place of service includes Office (11), Urgent Care (20), ER (23), Mobile Unit (15) or other appropriate POS; providers and participation status per policy.

Effective date for $0 member cost share for these visits: 03/18/2020 (applies per lines of business described in policy).

inv-04: Virtual visits / Telehealth

Covered when the following conditions are satisfied (virtual/telehealth services):

Service is a virtual visit/telehealth encounter billed with appropriate E/M or other applicable CPT codes (examples: 99201‑99215; telephone codes 99441‑99443 where applicable) and billed with GT or 95 modifier as required.

Place of service should generally be the regular POS as if seen in person; Out‑of‑home telehealth (02) and Telehealth in Home (10) are referenced where applicable.

Cost‑share treatment

Member's current cost share applies (standard).
Member's cost share waived for specified dates/groups per policy (e.g., waivers in effect 6/1/2020 until CMS directs otherwise; SAO Group waived 03/26/2020–08/31/2021).

Provider participation and types: many virtual visits require participating providers only; eligible provider types vary by line of business (Primary Care, Specialists, Behavioral Health contracted providers, CareCentrix home health contracted providers, qualified therapy professionals for PT/OT/ST as noted).

inv-05: Coverage and billing criteria

Additional coverage and billing rules (organized by topic):

Cost‑share waiver examples

SAO Group: cost share waived for members 03/26/2020 through 08/31/2021 (applies to specified services).
General virtual visit cost‑share waiver: member cost share waived for dates of service beginning 6/1/2020 until CMS directs otherwise (subject to line of business exceptions).

Medicare Advantage adjustments: Medicare Advantage virtual visit rules were adjusted/expired effective 05/07/2022; see policy for specifics on nursing home virtual visit codes and applicability.

Provider types allowed: Provider types include Primary Care, Specialists, Nursing Facilities, CareCentrix home health contracted providers, and qualified therapy professionals (PT/OT/ST) as noted; participation status may be participating only for some lines of business.

inv-06: Coverage rules

Summary of the key coverage positions and member cost‑share policies in this section:

Pre‑procedure testing: Covered when performed as part of the normal pre‑procedure work‑up using a 3‑hour test; reimbursement included in the global fee for procedures with pre‑procedure testing; expected within 24 hours of procedure when possible; submit ICD‑10 code Z20.822.

Testing during inpatient stay: Member cost share is waived for the COVID‑19 testing procedure; additional procedure codes billed with inpatient place of service (21) apply standard cost share.

Testing during outpatient stay: Member cost share is waived for the COVID‑19 testing procedure; additional procedure codes billed with outpatient place of service (22) apply standard cost share.

Virtual visits for State Group members: Teladoc and virtual visits were implemented at $0 cost share for State Group members effective March 26, 2020; $0 cost share expired August 31, 2021; State Group requires both audio and visual components (audio‑only not covered).

Coding: Test, Diagnosis, Procedure, and Modifier Codes

FDA-approved molecular/antigen test codes (partial list)mixedCovered

U0002	CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Test
U0003	2019-nCoV CDC Diagnostic Panel (non-CDC lab)
0240U	SARS-CoV-2 and Influenza A/B multiplex amplified probe technique
0241U	SARS-CoV-2 amplified probe technique

FDA-approved serology/antibody test codes (partial list)mixedCovered

86328	Antibody; infectious agent, not otherwise specified
86769	Antibodies to Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
0224U	SARS-CoV-2 antibody test, quantitative

Diagnosis and E/M/telehealth codes referencedmixed

B97.29	Other coronavirus as the cause of diseases classified elsewhere (used before 4/1/2020)
U07.1	COVID-19 (use for services on or after 4/1/2020)
Z20.822	Contact with and (suspected) exposure to COVID-19
Z03.818	Encounter for observation for suspected exposure to other biological agents ruled out
99000	Handling/processing services before/after direct patient care (example related to test visit)

Key procedure and modifier guidanceCPT

99000	Handling/processing services
99001	Handling/processing services, additional
GT	Modifier for telehealth services by synchronous telecommunication
95	Telemedicine service rendered via synchronous telecommunication
G0438	Annual wellness visit, initial
G0439	Annual wellness visit, subsequent
G2061	Remote evaluation of recorded video and/or images (Medicare Advantage only)
G2062	Telephone evaluation (Medicare Advantage only)

Therapy and allied health codesCPTCovered

97110

Therapeutic exercises

COVID-19 testing and diagnosis codesmixedCovered

B97.29	Other coronavirus as the cause of disease classified elsewhere (pre-4/1/2020)
U07.1	COVID-19 (for services on or after 4/1/2020)
Z20.822	Contact with and (suspected) exposure to COVID-19; use for testing per guidance
Z03.818	Encounter for observation for suspected exposure to other biological agents ruled out
B9729	B97.29 (alternate formatting) — other coronavirus as the cause of disease classified elsewhere (ensure mapping to B97.29)
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases

Provider Billing Actions and Operational Guidance

Documentation Required

Claims submission requirement

Submit claims using the following guidelines; all claims billed by a provider must effectively meet the accepted standard of care for the condition being treated. Check guidelines regularly as they will be updated and remain in effect until further notice.

Note

Provider participation and billing ability for virtual visits

Virtual visit coverage for certain scenarios is limited to participating providers; CareCentrix home health contracted providers are listed as able to bill for virtual visits in applicable lines of business effective 03/15/2020.

Note

Provider types eligible to bill

Primary care providers, specialists, nursing facilities and hospitals are identified as provider types able to bill for nursing home virtual visits and other virtual services; participation status and effective dates vary by line of business.

Nursing home virtual visit codes (e.g., 99304-99310, 99341-99350) must be billed with GT or 95 where indicated.
Place of service guidance: use regular POS as if in-person; Out-of-home telehealth (02) and Telehealth in Home (10) also referenced.

Billing Rule

Pre-procedure testing billing

Pre-procedure COVID-19 testing is covered when conducted as part of the normal pre-procedure work-up using a 3-hour test; reimbursement is included in the global fee for the procedure and providers should submit ICD-10 code Z20.822.

Florida Blue expects pre-procedure testing to be performed within 24 hours of the procedure whenever possible.

Documentation Required

Off-campus testing and DR condition code

Facilities operating COVID-19 testing at separate locations should submit a Hospital Outpatient Type of Bill (013x) using the facility's main address and NPI and include the DR (disaster related) condition code to flag the claim as COVID-19 testing.

Institutional claims for COVID-19 diagnosis/treatment should include DR and an appropriate diagnosis code (B97.29 for services before 4/1/2020; U07.1 on/after 4/1/2020; Z03.818; or Z20.828).
DR condition code should be used for COVID-19 related care occurring since Jan 27, 2020.

Billing Rule

Cost share for testing when part of inpatient/outpatient stay

Member cost share will be waived for the COVID-19 testing procedure when billed as part of an inpatient or outpatient stay; additional procedure codes billed with inpatient (21) or outpatient (22) places of service will apply the standard cost share.

Billing Rule

Urgent Care testing billing

Urgent Care Centers may bill procedure codes 87426, 87428, and U0003–U0005 with Place of Service Urgent Care Center (20) and an appropriate COVID-19 diagnosis code (B97.29, Z03.818, Z20.822, Z20.828, U07.1).

Billing Rule

Monoclonal antibody billing

If the monoclonal antibody drug was provided by the government, Florida Blue should be billed only for the administration using the appropriate CPT; for Medicare Advantage follow CMS guidance and do not bill the product if received free through USG-purchased inventory.

For Commercial plan patients bill Florida Blue for administration only when the drug was provided by the government.
For Medicare Advantage, providers must follow CMS instructions and not bill Florida Blue for product provided free; MA covers administration effective Jan 1, 2022.

Definitions and Billing Concepts

Covered COVID-19 lab tests — inv-22

Covered test typesFDA‑approved molecular/antigen and serology/antibody lab tests for COVID-19 are covered.

Example molecular/antigen codesSample covered codes include U0002, U0003, U0004, 87426, 87428, 87635.

Laboratory billing when drawing and processingLaboratories that both draw the specimen and process the test should bill CPT 87635 or HCPCS U0002 to represent the test.

Member cost shareFDA‑approved molecular/antigen and serology/antibody tests are covered at $0 member cost share (per guidance).

Virtual visits / telehealth — inv-23

Billing codes and modifiersVirtual visits/telehealth should be billed with applicable CPT codes (e.g., 99201-99215) and require GT or 95 modifier as specified.

Place of service guidanceUse the regular place of service as if the patient were seen in person; Out-of-home telehealth (02) and Telehealth in Home (10) are also referenced.

Provider eligibilityParticipating providers generally bill for virtual visits; specific eligible provider types include Primary Care, Specialists, CareCentrix home health contracted providers and qualified therapy professionals (varies by group).

Place of Service — inv-24

Primary POS rulePlace of service should be the regular place of service as if the patient were seen in-person for most telehealth visits.

Alternate POS codesOut-of-home telehealth services (02) and Telehealth in Home (10) are referenced for applicable scenarios.

Urgent Care POS for testingFor certain urgent care testing, use Place of Service 20 (Urgent Care Center) when billing specified test codes.

Specimen collection — inv-25

In-office specimen collectionFor an in-office visit, bill specimen collection with 99211 if no physician/QHP involvement, or 99212+ if a physician/QHP is involved.

Homebound/inpatient collectionUse procedure code G2023 for homebound or inpatient (not in a hospital) specimen collection.

SNF/home health collectionUse procedure code G2024 for skilled nursing facility and home health agency specimen collection.

Outpatient facility collectionUse HCPC C9803 for outpatient facility specimen collection.

DR condition code — inv-26

DR condition code useInstitutional claims for COVID-19 diagnosis or treatment should include the 'DR' (disaster related) condition code to flag claims impacted by the emergency.

Type of bill for off-campus testingFacilities operating testing at separate locations should submit a Hospital Outpatient Type of Bill (013x) using the main facility address and NPI and include the DR condition code.

Applicable diagnosis codes for institutional claimsUse B97.29 for services before 4/1/2020, U07.1 on/after 4/1/2020, Z03.818, or Z20.828 as appropriate alongside the DR code.

Pre-procedure COVID-19 testing — inv-27

Inclusion in global feePre-procedure COVID-19 testing performed as part of the normal pre-procedure work-up using a 3-hour test is covered and reimbursement is included in the procedure's global fee.

Expected timingFlorida Blue expects pre-procedure testing to be performed within 24 hours of the procedure whenever possible.

Coding guidanceProviders should submit ICD-10 code Z20.822 for pre-procedure COVID-19 testing per official coding guidelines.