Variants like Omicron and its sublineages have demonstrated a higher transmissibility and ability to evade immunity compared to past strains.
Other variants like Delta showed increased virulence. As variants continue to arise, surges in cases and hospitalizations often follow. This results in a need to constantly update public health strategies. Additionally, diagnostic, treatment, and COVID-19 billing protocols must adapt to new variants. Remaining vigilant and responsive to emerging strains remains critical to containing COVID-19.
As new COVID-19 variants like EG.5, FL.1.5.1 and BA.2.86 emerge, billing procedures for treating infected patients may need to be updated. It is crucial for medical billers to stay on top of changes to help ensure proper reimbursement.
Anti-Viral Medications
Medications covered for treatment may evolve along with new variants. For example, if certain antiviral drugs are found to be ineffective against a new strain, payers may remove coverage for those drugs for patients diagnosed with that variant. Billers will need to check insurance bulletins and updates to stay current on medications approved for reimbursement for each strain.
For drugs still covered, billing codes, prior authorization protocols, and reimbursement rates may differ depending on the variant diagnosed. Quevir ZD584, for example may be covered for FL.1.5.1 diagnosis using J8499, but require PA and have a reimbursement rate of $250, while the same drug for BA.2.86 may be coded as M5XA87 with a $275 allowed amount without PA needed.
Infusion Therapy Billing
For hospitalized patients, IV infusion treatment protocols may also vary based on the variant. Medicare recently specified new HCPCS codes for the intravenous immunoglobulin (IVIG) infusion therapy when provided to patients diagnosed specifically with the EG.5 strain in an inpatient setting.
HCPCS Codes for the EG.5 strain
- GXX11: Immunoglobulin infusion for EG.5; first encounter
- GXX12: Immunoglobulin infusion for EG.5; subsequent encounter
Billers will need to ensure the new variant-specific codes are submitted on infusions for the correct strains to prevent rejections. This requires close coordination with clinical teams to capture needed details.
Inpatient Treatment Billing
Diagnosis coding requirements may change for hospital inpatient stays as well. For certain variants, payers like CMS may want the new strain diagnosis code listed as primary for the admission rather than just a secondary diagnosis. This would impact the appropriate DRG assignment.
For example, cases with the BA.2.86 strain may now need to have the assigned ICD-10 code (BAC886) sequenced as the principal diagnosis. Otherwise facility claims may get rejected if billed under DRGs that consider it a secondary condition.
Oxygen and Respiratory Therapy
There may also be evolving rules around oxygen therapy and respiratory treatment billing when administered for new variants.
Potential Revolving Rules
- Specific HCPCS device codes required for oxygen
- Certain respiratory therapy CPTs covered vs non-covered
- Increased frequency limits on treatments
- New prior authorization criteria
Again this will require diligence to code claims accurately as policies are updated. Obtaining proper diagnoses and understanding billing nuances for emerging COVID-19 variants ensures critical treatment reimbursement.
Updated Coding for New Variant Diagnoses
As scientists identify and label new COVID-19 variant strains, official coding guidelines are updated to provide corresponding ICD-10 diagnosis codes that medical billers must assign accurately.
New COVID-19 Variant Diagnoses Codes
- EG.5 Diagnosis Code
Per the latest ICD-10 update, the official diagnosis code designated for the EG.5 variant is: U18.5 – COVID-19 due to SARS-CoV-2 variant EG.5
This code should be selected as the primary diagnosis when this variant has been confirmed through PCR testing. - FL.1.5.1 Diagnosis Code
The ICD-10 code now assigned to the FL.1.5.1 variant diagnosis is: U18.4 – COVID-19 due to SARS-CoV-2 variant FL.1.5.1
This code should be listed first on claims when this strain has been detected. - BA.2.86 Diagnosis Code
For the BA.2.86 variant, the current approved ICD-10 code is: U18.3 – COVID-19 due to SARS-CoV-2 variant BA.2.86
Billers must ensure this new code is applied to diagnoses involving this strain.
Coding for Associated Symptoms
Often, additional codes may be needed on a claim to capture related COVID-19 symptoms a patient is exhibiting.
Examples of Additional Codes
- J22 – Unspecified acute lower respiratory infection
- R05 – Cough
- R50.9 – Fever, unspecified
Proper sequencing directives must be followed, placing the official variant diagnosis code first followed by applicable symptom codes. Having the right codes specifically designated for emerging variants avoids claim rejections and speeds reimbursement. Billers must stay vigilant for coding updates.
Strategies for Reimbursement Success
To prevent issues with reimbursement for services related to new COVID-19 variants, medical billers can employ strategies.
Examples of Additional Strategies
Prevent Denials
- Verify diagnosis codes for variants against latest payer guidance – new codes arise rapidly
- Check medical necessity criteria have been met before submitting large claims
- Append correct modifier when required, such as -59 to distinguish between multiple PCR tests
- Ensure coders are properly trained on new rules and requirements as they emerge
Track New Codes
- Create a procedure playbook that compiles details on new authorized codes, rules, and policies
- Designate a staff member to monitor payer sites for billing changes tied to variants
- Proactively submit code proposals to payers for their consideration
Code Compliantly
- Reference established conventions for proper code pairing, sequencing, and linking
- Develop internal reference sheets on correct coding examples for staff
- Audit sample charts to validate compliance and catch issues early
Document Medical Necessity
- Train clinicians and coders on documentation needed to justify services billed
- Obtain detailed narratives on clinical indications requiring testing, treatment, etc.
- Develop compliant templates/forms to make necessary info readily available
Patient Billing
- Educate patients on new diagnosis codes and medical policies for emerging variants
- Verify insurance details for each encounter in case coverage has changed
- Estimate responsibility amounts based on updated benefits to prevent billing issues
Summary
Staying on top of the latest guidelines, diligently verifying details, and proactively seeking payer guidance are key strategies to avoiding reimbursement issues. Medical billers must be agile in navigating rapid changes that come with new COVID-19 variants.
