JN.1 Variant: Navigating COVID-19 Testing Billing Requirements and Optimization

CMS COVID Testing Billing

Medicare covers diagnostic COVID-19 testing with no cost-sharing when medically appropriate for beneficiaries. During the public health emergency, tests can be covered in a wider range of healthcare settings like parking lot drive-thrus and temporary tents when ordered by licensed practitioners.

Key CMS billing requirements include:

• Using assigned CPT codes based on test type – 87635 for PCR, 87426 for antigen, 0224U for antibody
• Appending the COVID-19 diagnosis code U07.1 on claims
• Not charging specimen collection separately
• Waiving deductibles and coinsurance that normally apply to lab tests
• Covering testing for employment or travel screening purposes, not just diagnostic tests

Common roadblocks under fee-for-service Medicare include:

• Denials for U0001 CPT code instead of the more specific 87635, 87426 options
• Lack of supporting diagnosis code U07.1 resulting in rejections
• Trying to separately bill specimen collection using codes like G2023, G2024

Optimizing Medicare testing claims requires staying on top of latest guidance, leveraging tools like the AMA’s COVID testing code search to ensure billing accurate CPTs, and confirming diagnosis codes link symptoms to justify necessity.

CMS guidance evolves rapidly, so relying on a specialized billing partner well-versed in requirements avoids lost revenue from avoidable denials. Auditing claims prior to submission adds a key control point to validate completion.

Many Medicare members are covered under Medicare Advantage managed care plans.

While CMS reimburses directly for fee-for-service claims, MA plans follow unique billing procedures:

• Most MA plans use the U0001 CPT and accept separate specimen collection charges
• Providers may need to submit an authorization request before testing
• Patient cost sharing varies more widely so benefits checks are critical

Again, every MA organization implements their own billing rules. Utilizing a centralized billing expert across multiple payers offers economies of scale in mastering COVID testing nuances benefitting both staff productivity and revenue optimization.

Commercial Payer COVID Testing Policies

Unlike Medicare’s universal coverage, commercial payers implement varied policies and restrictions around COVID diagnostic testing:

• Aetna covers drive-thru and pharmacy testing when ordered by a physician or appropriately licensed practitioner. Testing must be provided by CLIA-certified labs with Aetna typically reimbursing on a fee-for-service basis when coded with 87635, 87426, etc. Pre-authorization is not required.
• Cigna does not require pre-approval for medically necessary COVID-19 testing but clinical criteria must be met based on symptoms and exposure history. Testing solely for public health surveillance or return to work/school purposes may be denied without supporting medical justification.
• Humana follows CDC guidelines for testing coverage, requiring codes 87635, 87426, etc. and diagnosis U07.1. Pre-auth is not mandated and member cost sharing is waived for diagnostic testing until the public health emergency ends.
• UnitedHealthcare requires use of CPT code 87635 and U07.1 diagnosis code on claims. Testing must be provided by CLIA-certified labs with in-network agreements in place. Authorizations are typically not required.
• Insurance responses continue evolving amidst the public health crisis. Staying updated on coverage policies prevents billing missteps threatening revenue. While many plans follow common CMS guidelines, benefits checks and pre-authorization requirements vary.

Outsourcing billing to specialists with dedicated COVID response teams allows leveraging collective knowledge across hundreds of payers for smoother claim processing.

Additional leading practices include:

• Verifying eligible billing entities like independent labs vs outpatient facilities
• Checking plan-established limits on testing frequency that may flag excessive utilization
• Monitoring ambulance transport policies when specimens require shipping
• Tracing possible member expenses like copays or deductibles waived under federal mandates
• Appealing incorrect denials with medical records demonstrating medical necessity

The variability and rapid pace of changing COVID billing rules makes relying on billing experts prudent to avoid lost revenue amidst the ongoing public health response.

Optimizing Workflow Integration

Testing billing presents added challenges due to involvement of additional entities beyond just the ordering provider.

For example:

• Ordering physician collects nasal swab at clinic
• Specimen shipped to large national lab for analysis
• Test results interfaced to health system EMR
• Lab submits claims to payer directly

This adds complexity to tracking status and ensuring correct enrollment/affiliation data. Similarly, drive-thru testing sites involve hand-offs between collectors, labs, and communicators of results.

Streamlining workflow integration enhances billing success:

• Order requisitions contain complete, accurate patient demographics and insurance data
• Testing facilities maintain full orders and medical necessity documentation
• Results integrate back to ordering EMR to inform diagnosis coding
• Inventory and test utilization feeds inform lab billing volume

When using third-party labs, establishing data exchange routines prevents gaps that can delay claims filing and revenue recognition. Similarly, tightening internal systems integration improves documentation flow to meet medical necessity justification if challenged upon audit or denial appeals.

Special considerations like Medicare crossover claims that route from a commercial payer to supplemental Medicare coverage also come into play with COVID testing claims. Managing these complexities proactively prevents downstream bottlenecks.

Patient Billing and Collections

The Families First Coronavirus Response Act and subsequent mandate require commercial plans and Medicaid to fully cover COVID diagnostic testing costs during the public health emergency without member cost-sharing when tests are medically appropriate.

However, questions around coverage and patient cost still persist, resulting in unpaid claims exposure:

• Copays wrongly applied before insurers adapted claim adjudication systems to waive cost shares
• Deductibles in high plans that members erroneously paid before federal waivers enacted
• Incorrectly coded claims missing diagnosis linkages that fail waiver cost protections
• Confusing explanation of benefits miscommunicated as bills to untrained patients

Proactive financial counselors with specialized COVID testing billing knowledge alleviate common patient questions and issues to accelerate collections.

Key considerations include:

• Explaining waived cost-sharing protections and that EOBs are not bills requiring payment
• Refunding any COVID testing copays and deductibles incorrectly collected from patients
• Appealing claims with errors that resulted in patients receiving bills from insurers
• Setting pricing transparency and financial expectations for scenarios like workplace screening after waivers expire