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Provider Coronavirus Information

NEW TELEHEALTH POLICIES EXPAND COVERAGE FOR HEALTHCARE SERVICES

In order to ensure that all of our members have needed access to care, we are increasing the scope and scale of our use of telehealth services for all products for the duration of the COVID-19 emergency. These coverage expansions will benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to avoid clinical settings and other public spaces.

Effective immediately, the policies we are implementing include:

  • Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth*
          
  • Any services that can be delivered virtually will be eligible for telehealth coverage
         
  • All prior authorization requirements for telehealth services will be lifted for dates of service from March 17, 2020 through July 25, 2020|
           
  • Telehealth services may be delivered by providers with any connection technology to ensure patient access to care

*Please note: For Health Savings Account (HSA)-Qualified plans, IRS guidance is pending as to deductible application requirements for telehealth/telemedicine related services. 

Providers who have delivered care via telehealth should reflect it on their claim form by following standard telehealth billing protocols in their state. For further billing and coding guidance for telehealth services, we recommend following what is being published by:

We believe that these measures will help our members maintain access to quality, affordable healthcare while maintaining the CDC’s recommended distance from public spaces and groups of people. 

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

Wisconsin Medicaid is making frequent changes to benefits and processes during the COVID-19 pandemic. MHS Health monitors both CMS and ForwardHealth and implements changes accordingly. Providers are also encouraged to follow alerts and updates on the ForwardHealth website.

During the COVID-19 pandemic, MHS Health will not require notifications be sent for any existing practitioner that you have within your group/TIN that are serving members from another location within the same group/TIN (a location change only). We do, however, ask that you continue to send notifications to add a new practitioner to your group/TIN.  

Also, please indicate if this new practitioner will be temporary (COVID-19 coverage only) or a permanent addition.

We also understand that at this stressful and busy time, you may not be able to send us your monthly updates for Adds, Terms and Changes that are not related to the COVID-19 crisis. Please send us those updates when you have the resources to do so.

If you have questions or concerns, please reach out to us at MHS-WIPDM@mhswi.com.

PROVIDER BILLING GUIDANCE FOR COVID-19 TESTING, SCREENING & TREATMENT SERVICES

[Updated April 30, 2021] We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. The following guidance can be used to bill for services related to COVID-19 vaccinations, testing, screening and treatment services. This guidance is in response to the current COVID-19 pandemic and may be retired at a future date. For additional information and guidance on COVID-19 billing and coding, please visit Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA)

COVID-19 Vaccines

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for claims billed with the new COVID-19 vaccine codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
  • Per CMS guidance, all Medicare claims for the COVID-19 vaccine and its administration must be billed directly to Original Medicare fee-for-service (FFS).
  • All Medicare claims related to the COVID-19 vaccine codes will be denied, with direction to submit directly to Medicare FFS for payment
  • The following codes have been published as of February 22, 2021.

    NOTE: Vaccines will not be billable until the specific vaccine receives official EUA approval. Currently approved vaccines are denoted by their effective date below. 

COVID-19 Vaccines

Code CPT Short Descriptor Labeler Name Vaccine/Procedure Name Effective Date
91300 SARSCOV2 VAC3
0MCG/0.3ML IM
Pfizer Pfizer-BioNTech Covid-19 Vaccine 12/11/2020
0001A ADM SARSCOV2 VAC30MCG/0.3ML 1ST Pfizer Pfizer-BioNTech Covid-19 Vaccine
Administration – First Dose
12/11/2020
0002A ADM SARSCOV2 VAC30MCG/0.3ML 2ND Pfizer Pfizer-BioNTech Covid-19 Vaccine
Administration – Second Dose
12/11/2020
91301 SARSCOV2 VAC
100MCG/0.5ML IM
Moderna Moderna Covid-19 Vaccine 12/18/2020
0011A ADM SARSCOV2 VAC100MCG/0.5ML 1ST Moderna Moderna Covid-19 Vaccine
Administration – First Dose
12/18/2020
0012A ADM SARSCOV2 VAC100MCG/0.5ML 2ND Moderna Moderna Covid-19 Vaccine
Administration – Second Dose
12/18/2020
91303 SARSCOV2 VAC
AD26 .5ML IM
Janssen Janssen Covid-19 Vaccine 2/22/2021
0031A ADM SARSCOV2 VAC
AD26 .5ML
Janssen Janssen Covid-19 Vaccine
Administration
2/22/2021
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 vaccine payments.

COVID-19 Testing Services

  • Providers performing the COVID-19 test can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0001 - For CDC developed tests only - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
    • HCPCS U0002 - For all other commercially available tests - 2019-nCoV Real-Time RT-PCR Diagnostic Panel.
      Please note: It is not yet clear if CMS will rescind the more general HCPCS Code U0002 for non-CDC laboratory tests that the Medicare claims processing system is scheduled to begin accepting starting April 1, 2020.
    • CPT 87635 - Effective March 13, 2020 and issued as “the industry standard for reporting of novel coronavirus tests across the nation’s health care system.”
    • PLA 0202U* - Effective May 20, 2020. Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
  • These codes should not be used for serologic tests that detect COVID-19 antibodies.
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 testing services payments.

*Not covered by Wisconsin Medicaid

COVID-19 Antigen Testing Services

  • Providers performing COVID-19 antigen tests can bill us for testing services that occurred after June 25, 2020, using the following HCPCS codes:
    • 87426 - Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg SARS-CoV, SARA-CoV-2 (COVID-19).
    • 0223U* - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
    • 0224U* - Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease (COVID-19) includes titer(s), when performed (Do not report 0224U in conjunction with 86769).
  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the above COVID-19 antibody testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.*
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 antigen testing services payments.

*Not covered by Wisconsin Medicaid

High-Throughput Technology Testing Services

  • Providers performing high production COVID-19 diagnostic testing via high-throughput technology can bill us for testing services that occurred after February 4, 2020, using the following newly created HCPCS codes:
    • HCPCS U0003 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
      Please note: U0003 should identify tests that would otherwise be identified by CPT code 87635 but for being performed with these high throughput technologies.
  • HCPCS U0004 -2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
    Please note: U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies.
  • Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these codes to indicate high production testing.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 high-throughput technology services payments.men Transfers

COVID-19 Specimen Transfers

  • For specimen transfer related claims, the following codes can be used:
    • G2023* - Spec Clct for SARS-COV-2 COVID 19 ANY SPEC SRC
    • G2024* - SP CLCT SARS-COV2 COVID19 FRM SNF/LAB ANY SPEC
    • C9803 - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source. This is effective for services provided on or after March 1, 2020.
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 specimen transfer payments.

*Not covered by Wisconsin Medicaid

COVID-19 Screening Services

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
  • If no testing is performed, providers may still bill for COVID-19 screening visits for suspected contact using the following Z codes:
    • Z20.828 – Contact with a (suspected) exposure to other viral communicable diseases
    • Z03.818 – Exposure to COVID-19 and the virus is ruled out after evaluation
  • This applies to services that occurred as of February 4, 2020.
  • Providers billing with these codes will not be limited by provider type.
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 screening service payments.

COVID-19 Treatment Services

  • For dates of service of April 1, 2020 and later, providers should use the ICD-10 diagnosis code:
    • U07.1 – 2019-nCov Confirmed by Lab Testing
  • We will waive member cost sharing for COVID-19 treatment for all members for dates of service through May 31, 2021.
  • For dates of service June 1, 2021 and onward, providers should collect Medicare and Marketplace member cost share (copayment, coinsurance and/or deductible amounts) at the point of service.
  • Prior authorization requirements will continue to be waived for COVID-19 treatment services.

COVID-19 Monoclonal Antibody Infusion Services

  • All Marketplace and Medicaid member cost share (copayment, coinsurance and/or deductible amounts) will be waived for claims billed with the new COVID-19 monoclonal antibody infusion services codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes. This includes non-participating providers.
  • Per CMS guidance, all Medicare claims for monoclonal antibody infusion services must be billed directly to Original Medicare fee-for-service (FFS).
  • Medicare claims related to the monoclonal antibody infusion codes will be denied, with direction to submit directly to Medicare FFS for payment.
  • CMS has identified the following specific code(s) for the monoclonal antibody product and specific administration code(s) for Medicare payment:
    • Eli Lilly and Company’s Antibody Bamlanivimab (LY-CoV555), EUA effective November 9, 2020
      • Q0239 - Injection, bamlanivimab-xxxx, 700 mg
      • M0239 - Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
    • Regeneron’s Antibody Casirvimab and Imdevimab (REGN10933 and REGN10987), EUA effective November 21, 2020
      • Q0243 – Injection, casirvimab and imdevimab, 2400 mg
      • M0243 – Intravenous infusion, casirvimab and imdevimab, includes infusion and post-administration monitoring
  • We will employ the reimbursement rates established by CMS and our state regulators in accordance with provider contract terms for COVID-19 monoclonal antibody infusion service payments.