We’re actively working to monitor the new Coronavirus disease—COVID-19—and its impacts to make sure we provide our members the care they need when they need it while supporting our providers.
Coverage for members
From February 4, 2020 through September 30, 2021, THC will cover 100% of the cost (waiving deductibles, coinsurance and co-pays) of the following COVID-related services when medically necessary:
- COVID-19 screening and antibody testing (see additional details below).
- Other services related to diagnostic testing and the administration of the test, such as office visits, blood draws or specimen handling.
- Virtual Care
Prior Authorization Updates
THC is not waiving any authorization requirements at this time. THC will work with our physicians and hospitals to provide required authorizations in a timely manner.
Billing for COVID-19 Vaccines on or after December 1, 2020
- Providers seeking reimbursement for the vaccine for Medicaid enrollees must registered with the MDHHS Division of Immunization’s COVID-19 Vaccination Program. Registration and online applications can be found at https://www.michigagov/coronavirus/0,9753,7-406-98178_98156—,00.html.
- Providers must bill the procedure code and the cost of the vaccine at $0.00
- Administration will be reimbursed at Medicare fee schedule rates for all lines of business
- New CPT codes have been established
|Billing Code||Description||Medicaid Rate||Commercial Rate|
|0001A||Pfizer – 1st dose administration||$15.95||$16.94|
|0002A||Pfizer – 2nd dose administration||$26.73||$28.39|
|0011A||Moderna – 1st dose administration||$15.95||$16.94|
|0012A||Moderna – 2nd dose administration||$26.73||$28.39|
|91303||Johnson & Johnson (Janssen) vaccine||$0.00||$0.00|
|0031A||J & J administration||$26.73||$28.39|
Use CR or CS modifier for claims related to diagnosing COVID-19; facilities add condition code DR
Provider offices, urgent care and emergency rooms should bill us using a CR or CS modifier anytime the visit resulted in a COVID-19 test being ordered. Facilities should also use condition code DR to identify when the services provided resulted in a COVID-19 test being administered. To properly identify as a COVID-related visit, a diagnosis code of Z20.828 (Contact with and (suspected) exposure to COVID-19) is expected.
If you have claims that resulted in the administration of a COVID-19 test, you should rebill claims using a CR or CS modifier or DR modifier with condition code dating back to February 4, 2020. Using this modifier will ensure your patients have a $0 cost share for any visit and services related to the diagnostic testing and administration of the test.
These codes should not be added to services billed for treatment of COVID-19.
Virtual visits billing and coverage
Effective March 1, 2020 through September 30, 2021 at a minimum, we will allow credentialed providers to bill routine practice codes with a Place of Service 02 (to include GT modifier for Medicaid; GT or 95 modifier for Commercial). As of July 1, 2020, we will pay according to the non-facility Medicaid rate and no longer require a COVID diagnosis to waive patient cost share. The visit must follow the guidelines for the code billed, including time requirements.
What does this mean? Any credentialed practitioner can conduct a telemedicine visit, including wellness visits, and bill with a Place of Service 02 and the appropriate modifier, which identifies the visit as being virtual.
For example, office procedures billed with an evaluation and management (E/M) code of 99201-99215, when performed in real-time by credentialed providers through an interactive tool that can be audio-only, can have a Place of Service 02 with modifier added and receive the standard non-facility-based rate.
What’s not included? You cannot:
- Use codes that specify in-person or describe services that can only be performed in person
- Bill for services you’re not contracted to provide
- Perform services outside of your scope of practice, licensure or credentialing
- Bill behavioral health codes; Beacon Health is providing telemedicine visits without cost-sharing through their provider network.
Given the government’s notification, we’re temporarily suspending the requirement for HIPAA compliant systems and are also allowing for real-time, interactive audio-only telehealth encounters to service patients who don’t have internet access or audio-visual capabilities. This means that if you don’t have a virtual care tool in place, you can use non-public facing tools, like FaceTime, Facebook Messenger video chat, Skype, etc. You cannot use public-facing tools like Facebook Live, TikTok or chat rooms like Slack. See the Office for Civil Rights FAQ for more information.
Visit codes billable by physicians
THC reimburses fee-for-service for the below listed codes when billed with POS 02 on a professional claim. Co-pays and deductibles will apply based on office visits. Claims will be reimbursed based on the non-FAC fee at your contractual rate as of 6/1/2020.
- Telephone Visits – Commercial ONLY
- Evaluation & Management Codes – Commercial and Medicaid
- GT modifier is required for Medicaid
- Commercial can bill with modifiers GT or 95
Billing for COVID-19 lab tests
The Centers for Medicare and Medicaid Services (CMS) released the below codes for COVID-19 lab tests that can be used starting April 1, 2020 for dates of services starting February 4, 2020.For more information, see the CMS FAQ at https://www.cms.gov/files/document/cms-2020-01-r.pdf.
|Code||Type||Base fee||Facility fee||Note|
|86328||Anti-body testing||$37.45||$39.32||See the AMA’s website for more information. Codes must be billed with SC Modifier to indicate medical necessity.|
|87636||MA||MA||Manually priced at 34% of charges|
|87637||MA||MA||Manually priced at 34% of charges|
|87428||MA||NA||Effective 11/10/2020, Manually priced at 34% of charges|
|87811||MA||NA||Manually priced at 34% of charges|
For commercial rates, your contractual rate will be applied to the base fee.
The Michigan Department of Health and Human Services (MDHHS) advises you complete the Human Infection with 2019 Novel Coronavirus Person Under Investigation (PUI) and Case Report Form if a patient tests positive for COVID-19.
Starting April 1, add ICD-10 code U07.1 COVID19 when your patients have a diagnosis of COVID-19. Until April 1, you should continue to follow the CDC’s recommendation for coding.
Note that diagnosis code B34.2, Coronavirus infection, unspecified, would in generally not be appropriate for the COVID-
19, because the cases have universally been respiratory in nature, so the site would not be “unspecified.”
THC will cover antibody testing with no member cost share, COVID-19 testing (any type) when it is ordered by a provider and medically necessary. Testing is covered ONLY when medically necessary. Audits for medical necessity may occur
The antibody testing codes are 86328 and 86769.
The following list of diagnosis codes are not considered medically necessary for COVID testing and will deny as member responsibility.
|Diagnosis Code||Diagnosis Description|
|Z0000||Encounter for general adult medical examination without abnormal findings|
|Z0001||Encounter for general adult medical examination with abnormal findings|
|Z00129||Encounter for routine child health examination without abnormal findings|
|Z008||Encounter for other general examination|
|Z01411||Encounter for gynecological examination (general) (routine) with abnormal findings|
|Z0184||Encounter for antibody response examination|
|Z0189||Encounter for other specified special examinations|
|Z020||Encounter for examination for admission to educational institution|
|Z021||Encounter for pre-employment examination|
|Z022||Encounter for examination for admission to residential institution|
|Z023||Encounter for examination for recruitment to armed forces|
|Z026||Encounter for examination for insurance purposes|
|Z0271||Encounter for disability determination|
|Z0282||Encounter for adoption services|
|Z0289||Encounter for other administrative examinations|
|Z029||Encounter for administrative examinations, unspecified|
|Z0389||Encounter for observation for other suspected diseases and conditions ruled out|
|Z0489||Encounter for examination and observation for other specified reasons|
|Z08||Encounter for follow-up examination after completed treatment for malignant neoplasm|
|Z111||Encounter for screening for respiratory tuberculosis|
|Z113||Encounter for screening for infections with a predominantly sexual mode of transmission|
|Z114||Encounter for screening for human immunodeficiency virus [HIV]|
|Z1152||Encounter for screening for COVID-19|
|Z1159||Encounter for screening for other viral diseases|
|Z119||Encounter for screening for infectious and parasitic diseases, unspecified|
|Z1211||Encounter for screening for malignant neoplasm of colon|
|Z125||Encounter for screening for malignant neoplasm of prostate|
|Z131||Encounter for screening for diabetes mellitus|
|Z136||Encounter for screening for cardiovascular disorders|
|Z1383||Encounter for screening for respiratory disorder NEC|
|Z1389||Encounter for screening for other disorder|
|Z139||Encounter for screening, unspecified|
|Z228||Carrier of other infectious diseases|
|Z298||Encounter for other specified prophylactic measures|
|Z299||Encounter for prophylactic measures, unspecified|
|Z362||Encounter for other antenatal screening follow-up|
|Z3689||Encounter for other specified antenatal screening|
|Z419||Encounter for procedure for purposes other than remedying health state, unspecified|
|Z539||Procedure and treatment not carried out, unspecified reason|
|Z578||Occupational exposure to other risk factors|
|Z579||Occupational exposure to unspecified risk factor|
|Z655||Exposure to disaster, war and other hostilities|
|Z711||Person with feared health complaint in whom no diagnosis is made|
|Z7184||Encounter for health counseling related to travel|
|Z7189||Other specified counseling|
|Z7252||High risk homosexual behavior|
|Z789||Other specified health status|
|Z79818||Long term (current) use of other agents affecting estrogen receptors and estrogen levels|
|Z79891||Long term (current) use of opiate analgesic|
|Z79899||Other long term (current) drug therapy|