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COVID-19 Support Measures: Details and Coding Guidance

Physicians/Specialists
Facilities/Hospitals
Ancillary
Pharmacy
Publication Date: 
2020-06-01

We continue to be committed to the safety of the patients and communities that we serve together. We want to support your heroic efforts to address the COVID-19 outbreak. Here is detailed guidance on the temporary measures we’ve taken. 

To view the expiration dates and how each measure applies to different Blue Cross NC member segments* visit the coronavirus provider landing page.  

Click the links below to get more details and coding guidance on our current measures:

*Please note: When referenced, the following information applies to all Medicare Advantage plans offered or administered by Blue Cross and Blue Shield of North Carolina, including Experience Health. Additionally, we cannot guarantee benefits or reimbursement for other insurance plans, including other local Blues plans. For COVID-19 coverage for other local Blues plans, visit the Blue Cross and Blue Shield Association’s coronavirus site. For Federal Employee Program (FEP) members, visit the FEP website. For the latest CPT coding updates from the American Medical Association (AMA), visit the AMA website.  

Virtual Rounds: Provider FAQs and Slides

Blue Cross NC has been hosting regular Virtual Rounds to provide updates and answer questions on COVID-19. Click here to register, and view resources from the sessions below.

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Payment at Parity for Telehealth - Effective March 6, 2020  

Visits to providers that previously required an in-person encounter can be performed virtually and will be paid at parity with office visits as long as they are medically necessary, meet criteria in the updated Blue Cross NC Telehealth Corporate Reimbursement Policy, and occur on or after March 6, 2020. 

  • These temporary measures include virtual care encounters for patients that can replace in-person interactions across appropriate care settings, including outpatient clinics, hospitals, and the emergency departments. 
  • All specialties are included. Any licensed, contracted provider who typically sees patients in person for services that can be provided virtually through telehealth is allowed per our Reimbursement Policy. 
  • Some commercial members can access MDLIVE or Teladoc as a virtual care benefit, as noted on their member ID card.   
Telehealth Coding Guidance for Blue Cross NC Commercial Members*: 
  • Use Place of Service (02) for telehealth visits
    • Exception: Urgent care and facility providers should bill the same as if the services were face to face.
  • For providers or members who don’t have access to secure video systems, telephone/audio-only visits can be used for the virtual visit.
    • For audio-only visits: Use Place of Service (02) and modifier -CR (catastrophe/disaster-related). For visits that use video, you do not need to include the modifier. You only need Place of Service (02). ​
  • Modifiers -95 and -GT are allowed but not required.
  • For services that must be done in a face-to-face encounter (i.e. labs, injections), do not use Place of Service (02).

*Please note: For Blue Cross NC Medicare Advantage members, follow CMS guidelines for coding.

Detailed Clinical Scenarios and Coding for Telehealth:

The following scenarios reflect the updated Blue Cross NC Telehealth Corporate Reimbursement Policy. The policy is in effect for dates of service beginning March 6, 2020 and can be accessed here: https://www.bluecrossnc.com/document/telehealth.   

Please note: Most current member benefits for Commercial products exclude reimbursement for CPT ® 99441-3 and 98966-8. 

Clinical Scenarios 

Guidance (Most scenarios are for Commercial members unless otherwise noted)

1. Established patient seen by provider (i.e., PCP, urgent care, or specialist) with symptoms concerning for COVID-19 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. 

2. Same as #1, but patient or provider cannot use secure video function. 

Use this scenario only when patient or provider cannot use secure video function. Secure video visit is always preferable to an audio-only visit. In this case, an audio visit can be used.  Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99211-99215 plus Place of Service (02) and CR modifier for audio only encounter. 

3. New patient seen by provider (i.e., PCP, urgent care, or specialist) with symptoms concerning for COVID-19 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99201-99205 plus Place of Service (02).   

4. Same as #3 new patient with symptoms concerning for COVID-19 but patient or provider cannot use secure video function. 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99201-99205 plus Place of Service (02) and CR modifier for audio only encounter. 

5. Established patient was scheduled for a routine (non-COVID19 related) in-person outpatient visit but will now be seen for a virtual visit.  May be especially useful for patients who are high risk for serious illness per CDC guidance and consistent with strategy for social distancing.  

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99211-99215 plus Place of Service (02).  

6. Same as #5 routine (non-COVID19 related), but patient or provider cannot use secure video function. 

Use this scenario only when patient or provider cannot use secure video function. Secure video visit is always preferable to an audio-only visit. In this case, an audio visit can be used. Use standard evaluation and management CPT® or HCPCS guidelines, including coding based on time. Codes 99211-99215 plus Place of Service (02) and CR modifier for audio only encounter. 

7. New patient seen by provider (i.e., PCP, urgent care, or specialist) to establish care (non-COVID19 related). 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99201-99205 plus Place of Service (02).   

8. Same as #7 new patient (non-COVID19 related), but patient or provider cannot use secure video function. 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99201-99205 plus Place of Service (02) and CR modifier for audio only encounter. 

9. Patient seen by PCP provider for Medicare Annual Wellness Visit (AWV). 

Use standard HCPCS guidelines.  Codes G0438-G0439 plus Place of Service (02). If audio only, use Place of Service (02) and CR modifier. Include appropriate diagnosis codes for chronic conditions. Requires documentation of blood pressure, pulse, respiratory rate, height, and weight that should be documented during the benefit period.   

10. Patient seen by PCP provider for preventative service/wellness visit. 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99381-99397, 99401-99412 plus Place of Service (02).  If audio only, use Place of Service (02) and CR modifier.  Medicare Advantage does not cover 99401-99404. 

11. Patient in hospital confirmed or suspected COVID-19 infection but now stable. Hospitalist sees patient virtually to minimize contact. 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Code for appropriate level of hospital inpatient or observation care, plus Place of Service (02). 

12. Patient in hospital confirmed or suspected COVID-19 infection sees specialty consult through virtual visit. 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes 99251-99255 or G0406-G0408, plus Place of Service (02).  For Medicare Advantage must use G0406-G0408. 

13. Patient to be seen by behavioral health provider virtually. Patient is practicing social distancing and reluctant to come into clinic. 

Use standard evaluation and management CPT ® or HCPCS guidelines, including coding based on time. Codes may include but not limited to 90791-90792, 90832-90842, 90845, 90853, 90863,  99201-99215 plus Place of Service (02).  

14. Patient in ER with confirmed or suspected COVID-19 infection but stable.  ER provider sees patients virtually to minimize contact. Could apply to ER providers conducting visit to homebound patient, or offsite ER doctor seeing patient in the hospital 

Use standard evaluation and management CPT ® or HCPCS guidelines. Codes 99281-99285, plus Place of Service (02).  This is based on history and complexity of decision making and outcomes.  For Medicare Advantage members use G0425-G0427, plus Place of Service (02). 

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COVID-19 Vaccine Coverage

Blue Cross Blue Shield of North Carolina (Blue Cross NC) will cover COVID-19 vaccines that are FDA approved for emergency use authorization (EUA) at no cost for all members, both during the public health emergency and after. While additional guidance may be released by the North Carolina Department of Health and Human Services (NCDHHS) later, we’re providing you with critical information that is known at this time.

Provider FAQs

Click here to read the most recent FAQs on Blue Cross NC's coverage and coding for COVID-19 vaccines. (Last updated 4/15/2021)

Allocation and Distribution   

The vaccine will be allocated, distributed and administered to the public in phases based on availability determined by federal, state and local government authorities. Health officials have recommended, as interim guidance, that both health care personnel and residents of long-term care facilities be offered the COVID-19 vaccine in the initial phase of the vaccination program. 

Effective June 8, 2021, providers may receive an additional payment for the administration of the COVID-19 vaccine in the home setting.  Providers please use the following coding and billing guidelines.

  • All home vaccine administration claims should be filed with CPT code M0201, along with the appropriate CPT for the vaccine given.
    • This code can only be used if the sole purpose of the visit is for vaccine administration.
    • M0201 can only be used once per home per date of service.
    • If the vaccine is given to more than one person in the home on the same day, only one claim for M0201 may be filed.
Cost Coverage and Claims

During the public health emergency, the federal government will pay for the cost of the COVID-19 vaccine for all individuals. Additional costs associated with administering the vaccine (such as vaccine supplies, storage and provider costs) will be covered by either the federal government or the member’s health plan, depending on the member. 

Member Segment

Cost Coverage

Claims Submission Instructions

Members over 65 (Medicare and Medicare Advantage)

The federal government will pay all vaccine-related costs, with no cost to members during the public health emergency. 

 

During the public health emergency, providers should file claims related to the vaccine and administration of the vaccine directly to Traditional Medicare. 

 

If providers file vaccine-related claims with Blue Cross NC during the public health emergency, the system will deny the claim and advise the provider to file to Traditional Medicare for Medicare Advantage members.   

 

Commercial members, including non-grandfathered individual under 65 plans, small and large group (fully insured and self-funded) plans, transitional plans and student health plans

The federal government will pay for the cost of the COVID-19 vaccine. Blue Cross NC and Administrative Services Only (ASO) groups will cover vaccine administration fees during the public health emergency with no cost to members. 

Providers should submit claims to Blue Cross NC. See the table below for coding guidance.

Members on a grandfathered group plan

Vaccines will be available at no member cost-share during the public health emergency.  Blue Cross NC and Administrative Services Only (ASO) groups will cover vaccine administration fees during the public health emergency with no cost to members. 

 

Providers should submit claims to Blue Cross NC. See the table below for coding guidance.

Federal Employee Program (FEP)

Once an FDA-approved vaccine becomes available for COVID-19, all federal employee health benefit carriers are required to cover the vaccine without any member cost-sharing during the public health emergency. The FEP Operations Center is working with the FEP Director’s Office to implement this as quickly as possible once FDA-approved vaccines are available. 

 

Providers should submit claims to Blue Cross NC. See the table below for coding guidance.

 

 

 

After the public health emergency, Blue Cross NC will cover the cost of the COVID-19 vaccine with no cost-sharing to members, as part of our routine preventative care and immunization benefits in accordance with federal laws and regulations.  

Coding Guidance for Commercial Members

Providers should use the latest guidance from the American Medical Association when coding for the COVID-19 vaccine. The AMA has also created a tool to determine the appropriate CPT code combination for the type and dose of vaccine being used.

Additionally, retail pharmacies are able to file vaccine claims under the medical or pharmacy benefits for commercial members. 

Out-of-Network Providers

Blue Cross NC and ASO groups will cover vaccine administration fees for out-of-network (OON) providers during the public health emergency. Current federal regulations prohibit any provider from balance billing patients for the COVID-19 vaccine. 

Please note if you are not currently a participating provider with Blue Cross NC:

  • All out-of-state claims should be filed in the state in which the vaccine was administered.
  • For out-of-network providers in NC, once the claim is filed, please expect to be contacted to obtain your W-9 and an enrollment package will be sent to you so we may properly process your claim.  We need this information in order to pay directly.  If we do not get a response from you within 12 days, we will process the claim and make payment to the member.
  • For patients with out-of-state Blues plans (also known as the Home Plan), the final decision on claims payment and cost share waiver is solely up to the discretion of the Home plan and their medical policies and guidelines. Blue Cross NC (the Host plan) does not have the ability to provide specific details regarding the Home plan’s adjudication nor can we adjust or override their decision.

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ShapeNo Member Cost Share for COVID-19 Testing and Clinical Visits to Determine If Testing Is Necessary* - Effective March 6, 2020  

Blue Cross NC will waive member cost-sharing (including deductibles, copayments, and coinsurance) for allowed charges for COVID-19 testing or for a doctor visit or call to determine if testing is necessary. Specifically, there will be no member cost-share for COVID-19 testing or clinical visits to determine if testing is needed through virtual care visits, outpatient office visits, urgent care visits or ER visits. These changes are in line with the federal coronavirus relief package approved and signed into law on March 18, 2020. We continue to encourage the use of virtual visits as the first step to seeking testing. For guidance on COVID-19 testing, please visit the CDC website.

For the cost-share waiver to apply, COVID-19 testing methods must meet the following criteria: 

  1. Ordered by a licensed health care provider, 

  1. Determined as medically necessary by a licensed health care provider for the diagnosis and management of a member’s medical condition, and 

  1. Have been cleared, approved or given emergency use authorization (EUA) by the FDA  

With some of the largest laboratory facilities facing capacity challenges because of COVID-19, Blue Cross NC updated its list of in-network laboratory services providers. Many of the facilities on this list (updated June 25, 2020) could have capacity to handle testing at this time. Please note that testing capacity may change at any time.

Coding guidance for clinical visits to determine if testing is necessary:

Effective for dates of service from Aug. 1, 2020, through Jan. 31, 2021, for commercial claims:

Providers should use the -CS modifier to indicate any COVID-19 testing-related services that result in an order for or administration of a COVID-19 test:

  • The -CS modifier should be applied to diagnostic imaging, labs and physician encounters (both face-to-face and telehealth) to determine if testing is needed for individuals with COVID-19 symptoms.
  • Please do not use the -CS modifier if you are screening a patient for COVID-19 (i.e., pre-op testing services). The modifier only should be used for visits and services to determine if COVID-19 testing is necessary.
  • The -CS modifier is not required for the COVID-19 test itself.
  • If another modifier is required for reimbursement purposes (e.g. -26 on a radiology procedure or -CR to indicate audio only for a commercial telehealth visit), the -CS modifier may be placed in the second or third position.
  • Do not use -CS modifier for treatment of COVID-19 or any other diagnosis.
  • This coding guidance applies to Blue Cross NC fully-insured and State Health Plan. Medicare Advantage plans offered or administered by Blue Cross NC, including Experience Health, should follow CMS guidelines for use of the -CS modifier.

Effective for dates of service on or after Feb. 1, 2021 for commercial claims:

  • For dates of service on or after Feb. 1, 2021, you have three options to indicate waiving cost share for commercial claims. It is at the discretion of the provider to choose which is appropriate.  
    • CS modifier: Can be used to indicate diagnostic imaging, labs and physician encounters (both face-to-face and telehealth) to determine if COVID-19 testing is needed for a patient who has a confirmed or suspected exposure to COVID-19.
    • Z20.822: Contact with and (suspected) exposure to COVID-19 
      • Likely will capture the majority of encounters 
      • Place as the primary diagnosis on the claim line when contact/exposure is the reason for the encounter and the patient is asymptomatic 
    • Z11.52: Encounter for screening for COVID-19 
      • Can be used as the primary diagnosis on the claim line when screening is the reason for the encounter and the patient is asymptomatic 

For Medicare Advantage claims:

  • Medicare Advantage plans offered or administered by Blue Cross NC, including Experience Health, should follow CMS guidelines for use of the -CS modifier.
  • Use the HCPCS codes for billing the -CS modifier in MLN - SE20011 under the section labeled Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services. Please only use the -CS modifier on the codes listed in the links in the MLN. The links have files with codes and those are the only codes that should have modifier CS applied.
  • Additionally, providers should not apply the -CS modifier to any COVID-19 lab or administration codes for Experience Health and Blue Medicare members. These services do not have a member liability during the pandemic and do not require the modifier. If the -CS modifier is applied to a COVID-19 lab service, the claim will deny.

For members of other Blues plans:

  • Providers should use the number on the back of a patient’s ID card to verify benefits for other Blues plans as not all are waiving cost share in the same way that Blue Cross NC is. 
Coding guidance for COVID-19 testing:

Click here to view the complete list of COVID-19 testing codes (updated on Feb. 25, 2021).

Molecular (PCR) testing for the COVID-19 virus: 

  • The following codes are available for use after April 1, 2020: 

  • For non-CDC lab testing, use HCPCS code U0002 or U0003. This allows laboratories to bill for non-CDC laboratory tests, for SARS-CoV-2/2019-nCoV (COVID-19). 

  • The AMA released the CPT code 87635 that may be used by providers as another option to bill for testing for severe acute respiratory syndrome coronavirus 2 (SARS-2-CoV-2) (Coronavirus disease [COVID-19]). 

Collection of specimens for COVID-19 PCR test:

  • Outpatient facilities: CMS released C9803 for outpatient facilities to use when collecting the specimen but not performing the test onsite. 

  • Non-facility providers: When collecting the specimen with no other services performed (i.e. no physical exam), bill 99211 

    • Can be used for both new and established patients  

    • In order to apply cost share waiver, 99211 must be billed with one of the 2 diagnosis codes below (Note: This applies for dates of service before Aug. 1, 2020. As noted above, for dates of service on or after Aug. 1, 2020, 99211 or any other COVID-19-related service code should be billed with the -CS modifier): 

      • Z03.818   Encounter for observation for suspected exposure to other biological agents ruled out. 

      • Z20.828   Contact with and (suspected) exposure to other viral communicable diseases 

Antibody testing: 

  • The AMA released CPT codes 86328 and 86769.

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No Member Cost Share for COVID-19 Treatments** - Effective April 01, 2020  

Please note: This measure expires on March 31, 2021.

Blue Cross NC will waive member cost-sharing for COVID-19  treatments for both in-network and out-of-network providers. The company will reimburse providers in full at its in-network or Medicare rates in an effort to support them financially and administratively during this emergency. 

Blue Cross NC will also work to shield members from balance billing and will work with providers to ensure access to affordable care during this crisis. Blue Cross NC encourages out-of-network providers to accept our payment in full and to work together to shield North Carolinians from financial harm.  

Coding guidance for COVID-19 treatments:
  • Diagnosis code U07.1 should be in the principal or primary position on the claim. 
    • Exceptions include:
      • Sepsis present upon admission: A41.89 in the primary position/U07.1 secondary position
      • Pregnancy: O98.51x in primary position/ U07.1 in secondary position
      • HIV: B20 in primary position/U07.1 in secondary position
  • New codes effective Jan. 1, 2021:
    • The following should be used in the secondary position:
      • J12.82 - Pneumonia due to coronavirus disease 2019
      • M35.81 - Multisystem inflammatory syndrome
  • For dates of service on or prior to Dec. 31, 2020, U07.1 should not be used when billing for the test itself. U07.1 can be used when billing for the test itself for dates of service on or after Jan. 1, 2021.
  • The -CS modifier should not be used when billing for the treatment of COVID-19.

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Prior Authorization Waiver for COVID-19 Related Services - Effective March 06, 2020** 

Please note: This measure expires on March 31, 2021.

Blue Cross NC will waive prior authorization requirements for emergent non-elective inpatient admissions, durable medical equipment and post-acute care services that are medically necessary for COVID-19 related services. 

In-network, in-state facilities that are included in this waiver are those that provide emergency medical and behavioral inpatient levels of care, including acute care. Generally, the waiver applies to services that are medically necessary and required to allow patients to be moved urgently to the safest and most appropriate site of care so that limited health care resources are available to respond to the pandemic. 

Coding Guidance for COVID-19 Related Services:

Providers do not need a prior authorization for inpatient services, durable medical equipment, or post-acute care services to deliver medically necessary services for patients diagnosed with COVID-19.  If you submitted a claim for a service provided after March 6, 2020 that was denied due to lack of prior authorization, please re-submit your claim after March 21, 2020. Please note that you may choose to submit a prior authorization for review, even if one is not required by the health plan. 

  • Diagnosis code U07.1 should be in the principal or primary position on the claim. 
  • U07.1 should not be used when billing for the test itself.
  • The -CS modifier should not be used when billing for the treatment of COVID-19.

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*State Health Plan (SHP)members do not utilize Blue Cross NC pharmacy services and will follow the separate SHP prescription benefit policy. 

**Please note that self-insured employer groups have the option to opt-in to this benefit. As such, some members may be ineligible for cost sharing coverage and waiver of prior authorization if their employers do not elect to cover these benefits. SHP has opted into these measures. 

 

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