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CMS Adds New HCPCS COVID-19 Lab Code

  • by Steve Nesnidal, MD, CPC, AHFI
  • Oct 21, 2020, 14:54 PM
COVID Test Neg

CMS is adjusting its payment policy for COVID-19 laboratory tests starting in Jan 1, 2021. This latest CMS policy adjustment is an attempt to improve the current reality; some labs have been running batches of their tests less frequently, using less staff, and thus taking more than two days to turn around results, while billing for the higher reimbursement rapid throughput technology. With these new lab codes, CMS hopes to incentivize high throughput COVID-19 laboratory test results and ensure turnaround of results are provided in a clinically meaningful timeframe.

On and after 1/1/2021 date of service, in order to receive the higher payment from CMS during the Public Health Emergency, the new HCPCS code U0005 must be used to signify that the laboratory is effectively turning around their high throughput test (i.e. they were “completed within two calendar days of the specimen being collected, meaning, the results of the test[s were] finalized and ready for release”). 

New HCPCS COVID-19 Lab Code Aims to Speed Up Results

COVID-19 tests for virus positivity either detect SARS-COV-2 nucleic acid components or viral protein components. Some are rapid point-of-care tests, yet others must be sent to the laboratory for processing. Of those sent to the lab, CMS incentivized the subset that use rapid throughput technology (reported with HCPCS codes U0003 or U0004) by nearly doubling their payment to $100 per test, compared to approximate $51 for tests performed with standard technology.

When submitted along with one of the two primary high throughput lab codes U0003 or U0004, U0005 will essentially function as a $25 add-on payment code. In 2021, only submitters of U0003 or U0004 that also include code U0005 will earn the higher payment of $100 per test. Submitters unable to support the additional code of U0005 on high throughput tests will receive a lesser CMS payment of $75 per test. 

U0003 (for reporting the high throughput test approved by CDC)
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.
U0004 (for any non-CDC based high throughput test)
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.

In order to use U0005, the lab must have successfully completed results within two (2) calendar days on the majority of their high throughput tests (i.e. 51% of them) collected in the month prior to the line item’s date of service. CMS feels this payment adjustment will facilitate timely COVID-19 laboratory results.

Context4 Healthcare Products Keep Customers Up-To-Date

At Context4 Healthcare, we are leaders in identifying potential fraud, waste, and abuse like this. This rule is just one of thousands in our advanced pre-payment Payment Integrity solution, keeping your health plan assets safe. Learn more by visiting our Medical Payment Integrity page.

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