CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Temporary COVID-19 Testing and Treatment Services Payment Policy – Archive 10

Defines Neighborhood Health Plan of Rhode Island's temporary coverage and reimbursement requirements for COVID-19 diagnostic testing (PCR, antigen, antibody) and related outpatient visits and treatment during the Rhode Island COVID-19 State of Emergency for Medicaid, INTEGRITY, and Commercial lines of business. Applies to inpatient and outpatient treatment services and lab testing when medically appropriate per provider and RI Dept. of Health guidance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary COVID-19 Testing and Treatment Services Payment Policy – Archive 10

Policy CodePolicy N/A

Change TypeCoding & Cost-share updates

Effective Date

Next Review Date

Key ActionOrdering provider must determine the COVID-19 test is medically appropriate per accepted standards and RI Department of Health guidance; this determination may occur via traditional encounter, review of written/electronic survey, or approved algorithm.

SourceLink

POLICY UPDATE CHANGES

09/02/20 Update - Cost Share language to include before and after 7/21/20.

08/17/20 Update - Add new codes 0225U, 0226U, 86408, 86409 effective 8/10/20 and added language from OHIC and EOHHS guidance regarding PCR and Antigen testing issued 7/21/20.

07/13/20 Update - Add new codes 87426, 0223U, and 0224U effective 6/25/20.

06/24/20 Update - Add Code 0202U.

05/21/20 Update - Add code C9803.

05/13/20 Update - Add language regarding 'CS' modifier.

04/22/20 Update - Added new lab codes.

03/31/20 Update - Added treatment services criteria, Prior Authorization language, and updated claim submission criteria; Added new CMS G-codes.

03/25/20 Update - ICD-10 U07.1 effective 04/01/20.

03/17/20 Update - CPT code 87635 effective 03/13/20.

18Listed CPT/HCPCS codes

15Listed ICD-10 diagnosis codes

2020-03-13Earliest effective test code date

2020-09-02Last document update

Policy summary

Temporary policy documents Neighborhood Health Plan of Rhode Island's coverage and reimbursement requirements for COVID-19 testing and treatment during the Rhode Island COVID-19 State of Emergency; it applies to Medicaid, INTEGRITY, and Commercial lines of business. The policy covers laboratory diagnostic testing (PCR, Antigen, Antibody), related outpatient visits, and inpatient/outpatient treatment when the ordering provider determines the test or service is medically appropriate per accepted standards and Rhode Island Department of Health guidance. Neighborhood may implement, modify, or terminate this temporary policy without the standard 60‑day contractual notice, and any changes will be communicated to providers via notice on Neighborhood's COVID-19 Provider Guidance website.

PayerNeighborhood Health Plan of Rhode Island

Policy titleTemporary COVID-19 Testing and Treatment Services Payment Policy – Archive 10

Policy Number

StatusCURRENT

Last document update2020-09-02

Earliest effective test code date2020-03-13

What is covered

Coverage for Diagnostic Testing

Testing is covered when the ordering provider determines the test is medically appropriate in accordance with accepted standards of medical practice inclusive of RI Department of Health guidance; applies during RI COVID-19 State of Emergency.

ANY of the following

Symptomatic testing: any individual identified as symptomatic by a healthcare provider (symptoms include but are not limited to fever/chills, cough, shortness of breath, lowered oxygen saturation, fatigue, myalgia, headache, new loss of taste or smell, sore throat, congestion, nausea/vomiting, diarrhea, rash, inflammatory conditions such as 'COVID toes', thromboembolic events, trouble breathing, bluish lips or face, persistent chest pain/pressure, new confusion/altered mental status, alterations in blood glucose control, inability to wake or stay awake, children with multisystem inflammatory syndrome).
Asymptomatic - Close contact testing: Asymptomatic testing - Close contact testing: individuals identified as close contacts by state DOH, state-run contact tracing, or a healthcare provider. Close contact defined as being within <6 feet while case symptomatic or within 48 hours before symptom onset, direct contact with infectious secretions without PPE, or as defined by RI DOH.

Codes and diagnosis rules

PCR and Antigen testing CPT/HCPCS codes (covered)CPT|HCPCSCovered

0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including SARS-CoV-2, qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected. (effective 2020-05-20)
0223U	Infectious disease pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected. (effective 2020-06-25)
0225U	Infectious disease pathogen-specific DNA and RNA, 21 targets including SARS-CoV-2, amplified probe technique including multiplex RT, each analyte reported as detected or not detected. (effective 2020-08-10)
0226U	Surrogate viral neutralization test (sVNT), SARS-CoV-2, ELISA, plasma/serum. (effective 2020-08-10)
87635	Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2, amplified probe technique. (effective 2020-03-13)
87426	Infectious agent antigen detection by immunoassay technique; SARS coronavirus (eg SARS-CoV-2). (effective 2020-06-25)
U0001	CDC testing laboratories to test for SARS-CoV-2/2019-nCoV (COVID-19).
U0002	Non-CDC testing laboratories to test for SARS-CoV-2/2019-nCoV (COVID-19).
U0003	Infectious agent detection by nucleic acid; SARS-CoV-2, amplified probe technique using high throughput technologies as described by CMS-2020-01-R.
U0004	2019-nCoV Coronavirus, SARS-CoV-2 any technique, multiple types or subtypes, non-CDC, high throughput technologies as described by CMS-2020-01-R.

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Antibody testing CPT/HCPCS codes (covered)CPT|HCPCSCovered

0224U	Antibody, SARS-CoV-2, includes titer(s) when performed. (effective 2020-06-25)
86328	Immunoassay for infectious agent antibody(ies), qualitative or semi-quantitative, single step method; SARS-CoV-2. (effective 2020-04-10)
86408	Neutralizing antibody, SARS-CoV-2; screen. (effective 2020-08-10)
86409	Reporting SARS-CoV-2 neutralizing antibody titer. (effective 2020-08-10)
86769	Antibody; SARS-CoV-2.

Diagnosis codes for confirmed COVID-19 and related conditionsICD-10Covered

U07.1	2019-nCoV acute respiratory disease (use primary diagnosis field for confirmed cases on/after 2020-04-01).
B97.29	Other coronavirus as the cause of diseases classified elsewhere (used for confirmed cases prior to 2020-04-01 combined with condition code).
J12.89	Other viral pneumonia.
J20.8	Acute bronchitis due to other specified organisms.
J22	Unspecified acute lower respiratory infection.
J40	Bronchitis, not specified as acute or chronic.
J80	Acute respiratory distress syndrome.
J98.8	Other specified respiratory disorders.

Diagnosis codes for exposure/screening/symptoms (unconfirmed)ICD-10Covered

Z03.818	Encounter for observation for suspected exposure to other biological agents ruled out.
Z20.828	Contact with and (suspected) exposure to other viral communicable diseases.
Z11.59	Encounter for screening for other viral diseases.
R05	Cough.
R06.02	Shortness of breath.
R50.9	Fever, unspecified.

Modifiers (accepted)Modifier

CR	Catastrophe/disaster related (apply on professional claims for confirmed cases on/after 2020-04-01).
CS	Cost-sharing waived (accepted on claims for unconfirmed cases and accepted on the listed laboratory testing codes).

Claims Coding Requirements

Diagnosis coding rules for confirmed/unconfirmed/other scenarios and modifier usage

ALL of the following

Confirmed cases prior to 2020-04-01: Use primary diagnosis code per applicable condition combined with B97.29 (Other coronavirus as the cause of diseases classified elsewhere). Examples: Pneumonia due to COVID-19: J12.89 + B97.29; Acute bronchitis due to COVID-19: J20.8 + B97.29; Bronchitis NOS due to COVID-19: J40 + B97.29; Lower respiratory infection NOS/acute respiratory infection NOS: J22 + B97.29; Respiratory infection NOS: J98.8 + B97.29; ARDS due to COVID-19: J80 + B97.29.
Confirmed cases on or after 2020-04-01: Professional claims: Use ICD-10-CM code U07.1 in the primary diagnosis field and apply modifier 'CR' (Catastrophe/disaster related). Facility claims: Use ICD-10-CM code U07.1 in the primary diagnosis field.
Unconfirmed cases and exposure/screening:

Billing, documentation & operational actions

Documentation Required

Medical appropriateness required for testing

Ordering provider must determine the COVID-19 test is medically appropriate in accordance with accepted standards of medical practice and Rhode Island Department of Health guidance. This determination may be made during a traditional encounter, via review of written/electronic survey responses, or by an algorithm approved by a licensed provider and RI DOH. Refer to the testing criteria in the policy for covered symptomatic, asymptomatic, and other scenarios.

Determination may be made via encounter, survey review, or approved algorithm — see policy testing criteria.

Prior Authorization

No prior authorization for diagnostic lab testing

Prior authorization does not apply to diagnostic laboratory testing for COVID-19.

Operational billing rules

Billing/Specimen Collection Rules

Operational billing rules for specimen collection and claims submission

Communication of results: Communication of test results is standard practice and is not separately billable.

Specimen collection bundling: Specimen collection is considered part of testing and not separately reimbursable when billed on the same day by the same supplier as an E&M service or laboratory test.

No prior authorization: Prior authorization does not apply for diagnostic laboratory testing for COVID-19.

Contractual agreements: Billable services are subject to contractual agreements when applicable.

Key terms

Definitions

Close contactBeing within less than 6 feet of a COVID-19 case while symptomatic or within 48 hours before symptom onset; direct contact with infectious secretions without appropriate PPE; or as otherwise defined by Rhode Island Department of Health (references RI Department of Health definition).

Policy updates timeline

03/17/20added

03/17/20 Update - CPT code 87635 effective 03/13/20. (Added initial SARS-CoV-2 NAAT CPT code)

03/25/20revised

03/25/20 Update - ICD-10 U07.1 effective 04/01/20. (Updated coding instructions to use new ICD-10 code for COVID-19 after 2020-04-01.)

03/31/20revised

03/31/20 Update - Added treatment services criteria, Prior Authorization language, and updated claim submission criteria; Added new CMS G-codes. (Expanded policy to include treatment coverage and billing guidance for COVID-19.)

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTemporary COVID-19 Testing and Treatment Services Payment Policy – Archive 10

Policy CodePolicy N/A

Change TypeCoding & Cost-share updates

Effective Date

Next Review Date

SourceLink

On This Page

Asymptomatic - Known or suspected exposure: Asymptomatic testing - Known or suspected exposure where ordering provider determines test medically appropriate per standards and RI DOH guidance; 'suspected exposure' may be based on circumstances causing provider to suspect reasonable risk of exposure.

Asymptomatic - Resolution/admission/pre-procedure: Asymptomatic testing - Testing to determine resolution of infection when ordered by provider as medically appropriate per standards and RI DOH guidance; testing upon or prior to admission to a Rhode Island healthcare facility when ordered by provider as medically appropriate per standards and RI DOH guidance; testing prior to undergoing a medical procedure when ordered by provider as medically appropriate per standards and RI DOH guidance.

Non-traditional ordering scenarios: testing ordered after provider review of written/electronic survey responses without face-to-face/real-time encounter, or via algorithm approved by provider and RI DOH that determines medical appropriateness.

Diagnostic intent: Testing primarily for individualized diagnosis/treatment is covered even if it may also serve/appear to serve secondary purposes (e.g., workplace requirements).

ALL of the following

Antibody testing is covered as outlined in this policy.

ALL of the following

Statement of coverage: PCR and Antigen testing and the administration of such tests where an ordering provider has determined the test is medically appropriate for an individual in accordance with accepted standards of medical practice, inclusive of guidance issued by the Rhode Island Department of Health are covered as outlined in this policy.

Antibody Testing

Antibody/serology testing coverage

Antibody testing is covered as outlined in this policy.

Treatment Services

Inpatient and outpatient services for treatment of members diagnosed with COVID-19 are covered during the RI State of Emergency when medically necessary.

Treatment services required for members diagnosed with COVID-19 are covered.

Cost Share Waiver Criteria

Conditions under which member cost share is waived for Commercial plans.

ANY of the following

Date of service prior to 2020-07-21: Neighborhood will waive all member cost share for Commercial plans for laboratory diagnostic testing, related outpatient visit for COVID-19, and treatment for members diagnosed with COVID-19 during the period of heightened concerns related to COVID-19.
Date of service on or after 2020-07-21 and throughout the RI COVID-19 State of Emergency: Neighborhood will waive all member cost share for Commercial plans for PCR and Antigen testing and related outpatient visit for COVID-19 and treatment for members diagnosed with COVID-19.
Antibody testing not waived: Cost sharing will NOT be waived for Commercial plans for Antibody laboratory diagnostic testing.

Possible exposure ruled out: Z03.818; Exposure to someone with confirmed COVID-19: Z20.828; Asymptomatic screening with no known exposure and unknown/negative results: Z11.59; Members presenting with symptoms and screened with unknown/negative results: use symptom codes as applicable (R05, R06.02, R50.9) or Z03.818 or Z20.828 as applicable. Modifier 'CS' (Cost-sharing Waived) is accepted on claims for unconfirmed cases of COVID-19.

Billing Rule

Specimen collection bundling

Specimen collection is considered part of testing and is not separately reimbursable when billed on the same day by the same supplier as an E&M service or a laboratory test.

C9803
G2023
G2024

Billing Rule

Claims submission timeframe

Providers must submit complete claims for payment within 90 days of the date services are provided to members.

Billing Rule

Modifier usage for confirmed/unconfirmed cases

For confirmed COVID-19 cases on or after 2020-04-01, use ICD-10-CM code U07.1 in the primary diagnosis field; professional claims should also apply modifier CR (Catastrophe/disaster related). Modifier CS (Cost-sharing Waived) is accepted on claims for unconfirmed cases and on the listed laboratory testing codes to indicate waived cost-share.

U07.1
CR
CS

Denial Risk

Cost share collection prohibition

Do NOT collect cost share from Commercial members for covered PCR/Antigen testing, the related outpatient visit, and treatment during the applicable periods specified in the policy. Collecting cost share contrary to this policy may result in claim denials or recoupment per contract rules.

Claim submission timeframe: Providers must submit complete claims for payment within 90 days of the date services are provided to members.

Operational note: Neighborhood accepts modifier CS (Cost‑sharing Waived) on claims for unconfirmed COVID-19 cases and on the listed laboratory testing CPT/HCPCS codes to indicate waived member cost share; however, cost‑share waivers do not apply to Antibody testing for Commercial plans.

04/22/20added

04/22/20 Update - Added new lab codes. (Initial expansion of covered lab CPT/HCPCS codes.)

05/13/20added

05/13/20 Update - Add language regarding 'CS' modifier. (Allowed cost-sharing waived modifier on unconfirmed cases and testing codes.)

05/21/20added

05/21/20 Update - Add code C9803. (Added outpatient specimen collection code.)

06/24/20added

06/24/20 Update - Add Code 0202U. (Added multiplex PCR code.)

07/13/20added

07/13/20 Update - Add new codes 87426, 0223U, and 0224U effective 6/25/20. (Added additional PCR/antigen and antibody codes.)

08/17/20added

08/17/20 Update - Add new codes 0225U, 0226U, 86408, 86409 effective 8/10/20 and added language from OHIC and EOHHS guidance regarding PCR and Antigen testing issued 7/21/20. (Expanded covered testing codes and incorporated state guidance.)

09/02/20revisedLatest

09/02/20 Update - Cost Share language to include before and after 7/21/20. (Clarified cost-share waiver periods for commercial plans pre- and post-2020-07-21.) (MATERIAL)