Provider Coronavirus Information

For coronavirus information related to Ambetter from Coordinated Care, visit our Coronavirus Guidance page for providers on our Ambetter web site. 

Skip to CMS Billing Guidelines for COVID-19 Vaccine

Screening and Treatment Guidance for COVID-19

Coordinated Care is working to quickly address and support screening, testing and treatment for COVID-19, and is closely following guidance from the Centers for Medicare and Medicaid Services (CMS). As of April 1, 2020, the following guidance can be used to bill for services related to the screening and treatment of COVID-19.

COVID-19 Screening Services

• 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.

COVID-19 Treatment Services

• Coordinated Care will waive prior authorization requirements for COVID-19 treatment for all members.
•  For dates of service from February 4, 2020 through March 31, 2020 providers should use the ICD-10 diagnosis code: 
  • B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere
•  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

As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization waivers.

The Washington State Health Care Authority (HCA) has provided guidance to support opioid treatment program (OTP) medical directors relating to the corona virus (COVID-19) situation in Washington. This guidance contains recommendations and resources from state and federal partners. Review HCA's Frequently Asked Questions about COVID-19 and Opioid Treatment Programs (PDF). 

Provider Billing Guidance for COVID-19 Testing

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 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 the resource centers of the Centers for Medicare and Medicaid (CMS) and the American Medical Association (AMA).  

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.
  • 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.”

• These codes should not be used for serologic tests that detect COVID-19 antibodies.
• 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.

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.
• Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.

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.

Specimen transfers are currently a non-covered service per Health Care Authority (HCA) fee schedules.

COVID-19 Screening Services

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.

COVID-19 Treatment Services

We will waive prior authorization requirements for COVID-19 treatment for all members.

For dates of service from February 4, 2020 through March 31, 2020 providers should use the ICD-10 diagnosis code:

• B97.29 – Confirmed Cases – other coronavirus as the cause of diseases classified elsewhere

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
• Annual face to face visit requirements have been waived for reauthorization of respiratory equipment and supplies due to the current COVID-19 crisis; initiation of treatment still requires an in person assessment to collect relevant physical examination.

As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization waivers.

Established Reimbursement Rates for COVID-19 Testing Services for All Provider Types*

• We are complying with the rates published by Health Care Authority (HCA) for the following codes:
  • U0001 
  • U0002 
  • U0003 
  • U0004 

• Any additional rates will be determined by further HCA guidance and communicated when available.

Telehealth for Apple Health (Medicaid)

For our Apple Health (Medicaid) members, Coordinated Care covers telemedicine services provided by our community providers in accordance with all Health Care Authority (HCA) policies and guidelines as outlined in HCA’s published billing guidelines and fee schedules.

• For Apple Health members, visit our Coordinated Care telehealth page.
• For Apple Health (Medicaid) providers, please refer to the HCA telehealth FAQ (PDF).
• We recommend all providers refer to the HCA clinical and policy guide for COVID-19 (PDF).
• In addition, Coordinated Care contracts with Teladoc, a telehealth provider network. Teladoc delivers 24-hour access to in-network healthcare providers for non-emergency health issues at no cost.
• Members can receive medical advice, a diagnosis, or a prescription for colds, flu, fever, rash/skin conditions, sinuses/allergies, respiratory infections, and behavioral health.
• For more information on Teladoc, visit the Teladoc web site. 
• HCA has purchased a limited number of licenses for Zoom, a video conferencing technology platform that helps providers with telehealth visits. Please visit HCA’s website to see if you are eligible and to apply for this benefit.
• For more COVID-19 information from HCA, visit their COVID-19 web page.

Behavioral Health and Billing During COVID-19

HCA's Behavioral Health Policy and Billing FAQ (PDF) reinforces the state's current policies regarding telemedicine as defined in WAC 182-531-1730 and covers new telehealth policies that will only be in effect during this health care crisis.

Health Home (HH) and Home Visits

• Per CDC guidelines and CMS guidance, we are not currently doing any home visits with our members. 
• We are following HCA’s Health Home Guidance (PDF).

Alien Emergency Medical COVID-19 Coverage Expansion

• Alien Emergency Medical (AEM) clients can access care within the provider’s office setting (outside of the emergency department, inpatient and other outpatient settings) to diagnose and treat COVID-19.
  

General claims processing, including initial bills and appeals

• We do not anticipate issues and will continue to operate as normally as possible. If there is an issue where we cannot process claims, we will notify you.
• For fastest payment, enroll in EFT.

Existing Authorizations 

• As the pandemic continues, we have extended existing authorizations. We will continue to re-evaluate extensions as needed. 
• If you have questions on a specific authorization, please check the Provider Portal for an updated status.
  
  

COVID-19 Vaccine Administration

Providers

• Must have enrolled with either Washington State Department of Health or the Centers for Medicare & Medicaid Services (CMS) to administer COVID-19 vaccine shots.
• Must have a Core Provider Agreement with Apple Health (Medicaid) whose scope of practice includes vaccine administration. 

Pharmacist/Pharmacies

• Pharmacists may prescribe, administer, and bill for COVID-19 vaccine administration.
• Apple Health will reimburse for COVID-19 vaccine administration when administered by a pharmacy technician or a pharmacy intern under immediate supervision of a pharmacist with an ancillary utilization plan (AUP) approved by the Pharmacy Quality Assurance Commission. To bill for these services, the pharmacist who delegates the task should be entered as the servicing provider.
• Clinics billing for this service when performed by a pharmacist should follow the standard billing procedures.
• Pharmacists billing for this service must bill on a HIPAA 837 transaction using the billing taxonomy of 193200000X.
• Pharmacies may bill for COVID-19 vaccine administration when the performing provider is a pharmacist.

For Coordinated Care, bill as a pharmacy point-of-sale transaction and follow NCPDP standards: 

• Professional Service Code: MA 
• SCC: 2 – other override for 1st dose 
• SCC: 6 – Starter Dose for final dose of 2 dose vaccine
  

Reimbursement information and billing guidance (Revised 5/12/2021)

The vaccines and vaccine administration codes listed in the table below, are covered by Apple Health (Medicaid).

When billing for vaccine administration, HCA is no longer requesting that you bill the vaccine with the vaccine administration code. If you submit a claim with both the vaccine and the vaccine administration codes, HCA (Medicaid) will pay for the vaccine administration fee but will not pay for the vaccine itself since the COVID-19 vaccine is provided by the federal government without charge. If the COVID vaccine administration is the only service provided, then do not bill for an E/M.

Indian Health Service Providers

The encounter rate is payable for Medicaid covered professional services following the Tribal Health Billing Guide. The encounter rate is not payable for drugs/pharmaceuticals.

FQHCs and RHCs

COVID-19 counseling codes 99211-99215, 99401, and 99441-99443 are encounter eligible for FQHCs and RHCs when billed by an encounter eligible provider as outlined in WACs 182-548-1300(1) and 182-549-1300(1). The agency pays for one encounter per day for FQHCs and RHCs unless there are separate visits with separate diagnosis; or the visits are performed by providers with different specialties. Registered nurses and medical assistants are not encounter-eligible provider types in the RHC and FQHC setting.

Outpatient Hospital (OPPS) (Revised 3/8/2021)

When billing for the vaccine and the vaccine administration in an OPPS setting, the location revenue code must be used, not the vaccine administration revenue code. Any claims that have been denied due to noncoverage of revenue code 0771 should be resubmitted with the location revenue code for services provided for dates of service prior to February 15, 2021.

Effective for dates of service on and after February 15, 2021, when billing for COVID vaccine and vaccine administration in an OPPS setting, use revenue code 0771. This policy does not apply to other vaccines.

Please see the COVID-19 fee schedule for rates and effective dates.  Also please reference revisions made to the Apple Health COVID-19 Vaccine Clinical Policy (PDF).

The following codes have been published as of January 25, 2022. 

COVID Vaccine and Vaccine Administration Table

The additional payment for administering the COVID-19 vaccine in the home is covered for the following:

• The patient has a condition that makes them more susceptible to contracting a pandemic disease such as COVID-19. 
• The patient is generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort. 
• The patient has a disability or faces clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home. 
• The patient faces challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving.

For more information please see the CMS policy Additional Payment for Administering the Vaccine in the Patient’s Home.

Provider Reimbursement for COVID-19 Vaccine Counseling Visits

Counseling Visits

A counseling visit is a conversation between a provider or qualified health professional, nurse, or medical assistant, and a patient about the COVID-19 vaccine. Conversations may include topics such as patient's reasons for not being vaccinated, addressing concerns identified by the patient, providing tailored and individualized medical advice regarding COVID-19 vaccine for that patient, and providing resources about how to get a COVID-19vaccine if applicable. Counseling Visits should be documented in a patient’s medical record according to standard documentation guidelines.

Vaccination Status

The provider must check a client's vaccination status in the provider's medical records and the Department of Health WAIIS database. Immunization registry checks may be performed within a reasonable timeframe of the vaccine counseling visit to accommodate for data lags. If there is no indication that the patient is vaccinated, or there is indication that the patient is only partially vaccinated, the provider can reach out to the client for a counseling visit. If immunization registry checks are infeasible, client attestation to vaccination status is acceptable.

Billing Information

Providers and qualified health professionals

Providers who counsel patients about COVID-19 vaccine information and availability can bill in the following ways (Please review AMA CPT ® guidelines for code guidance):

1. If the provider is already seeing the patient for a prescheduled visit, and counseling for COVID-19 vaccination increases complexity of the visit or the time spent with the patient, the provider may account for this by choosing the appropriate E/M level. 
2. The provider may bill 99401 using modifier 25 in addition to billing EM visit. The E/M visit in this case should not include the time spent on COVID counseling. 
3. The provider may bill 99401 individually, if no E/M visit occurred and COVID vaccine counseling was provided. 

Nurses/Medical Assistants

Nurses and medical assistants who counsel patients about COVID-19 vaccine information and availability can bill using CPT® code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal.

Other Billing Details

• The claim must include the ICD-10 diagnosis code Z71.89 (other specified counseling) in the primary position and the CR modifier. 
• Providers performing Counseling Visits should be prepared to provide vaccine or be able to refer to appropriate, accessible vaccine sites for the member in counseling. 
• If the patient receives the vaccine in office after a counseling visit, additionally use the appropriate CPT codes for Vaccine Administration which may be billed the same date of service. 
• Telemedicine (real time audio visual) visits can be billed with place of service 02 (see Physician- related /professional services billing guide for more detailed information). 
• Use POS 10 for when patient is at home starting January 1, 2022. Note: Providers may begin billing using POS 10 on 1/1/22, but HCA has extended the effective date to 4/4/22. 
• During the Public Health Emergency (PHE), Use –CR modifier to denote when service provided over the phone/audio-only. Use FQ modifier starting January 1, 2022 
• If this service is provided via audio-only then the provider must obtain patient consent for the billing in advance of the service being delivered. 
• No facility fee can be charged for counseling billed by a hospital owned or affiliated physician practice or other practice site.
   

Materials to assist provider conversations with patients:

• Talking points for providers (PDF) 
• Provider Discussion Guide: Building Confidence in the Johnson & Johnson Vaccine (PDF) 
• Provider Discussion Guide: Building Confidence in COVID-19 mRNA Vaccines (PDF) 
• CDC's COVID-19 vaccine for preteens and teens
• CDC's COVID-19 vaccine conversations with patients
• Washington State DoH: Additional resources for healthcare providers 
• Pro-Equity strategies for supporting patient access to vaccine

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine.

If you have any further questions about vaccines or the COVID-19 services that Coordinated Care covers, please contact Provider Services at 1-877-644-4613.