Agencies
Services
Provider Notice Issued 02/26/2021
- the test is completed in two calendar days or less, and
- the lab completes the majority (51% or more) of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients in the previous month
Date: February 26, 2021
To: Enrolled Physicians, Advanced Practice Nurses, Physician Assistants, Independent Laboratories, Local Health Departments, Federally Qualified Health Centers, Rural Health Clinics, and Encounter Rate Clinics
Re: Update to COVID-19 Diagnostic Testing Codes and Rates Effective March 1, 2021
This notice informs providers of an update to coding and reimbursement for COVID-19 diagnostic tests run on high-throughput technology in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS), which is intended to incentivize expedited COVID-19 test results. This billing guidance applies to claims for participants covered under both traditional Medicaid fee-for-service and the HealthChoice Illinois Medicaid managed care plans.
Effective with dates of service March 1, 2021, reimbursement rates for HCPCS codes U0003 and U0004 will be reduced from $100.00 to $75.00 in accordance with CMS’ assessment of the resources needed to perform those tests and the corresponding Medicare rate reduction. Also effective with dates of service March 1, 2021, reimbursement will be available for the HCPCS add-on code U0005 at a rate of $25.00, provided the following requirements established by CMS are met:
According to CMS, a test is eligible for billing and payment of the U0005 add-on code for the same test for which U0003 or U0004 was billed if 51% or more of a lab’s COVID-19 tests for the calendar month previous to the test’s date of service were “completed” within two calendar days of collection. For example, if a test date of service is April 10th, whether or not a provider could bill the U0005 add-on code would be determined by the provider’s turnaround times for March 1st-31st. In this scenario, if 51% or more of the tests performed between March 1st-31st were completed within two calendar days, then all COVID-19 tests completed using high-throughput technology in the month of April are eligible for reimbursement of U0005 (so long as the test in question was also completed within two calendar days of collection), absent any billing errors that would otherwise result in rejection of the claim. The term “completed,” according to CMS, means the test results are finalized and ready for release.
It is the responsibility of the provider to maintain self-certification and supporting documentation of the above conditions. Providers are attesting to having met those conditions by billing the Department for the U0005 add-on code. Failure to adhere to the above conditions while continuing to bill U0005 shall be considered inappropriate billing subject to recoupment upon post-payment review.
The COVID-19 Fee Schedule will be updated with the coding and reimbursement information below:
State Max Amount Effective for Dates of Service 4/14/20 – 2/28/21 |
State Max Amount Effective for Dates of Service Beginning 3/1/21 |
|
U0003 |
$100.00 |
$75.00 |
U0004 |
$100.00 |
$75.00 |
U0005 |
N/A |
$25.00 |
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Kelly Cunningham, Administrator
Division of Medical Programs