AI Solutions for Healthcare

Changes to Payments for High Throughput COVID-19 Tests

HCPCS Codes U0003 and U0004

The expediency and accuracy of COVID-19 test results are a public health issue that can affect everyone in the social network of the person potentially exposed to coronavirus.  In mid-April 2020, the CMS approved HCPCS codes U0003 and U0004, which are high throughput COVID-19 tests, and the CMS authorized a reimbursement of $100 per test.  The expectation of high throughput, molecular diagnostic technology was expedited laboratory processing by highly trained staff handling hundreds of COVID-19 specimens per day.  Empirical analysis of test result timeliness and the resources needed to perform high throughput tests has prompted the CMS to reconsider payment methodologies and coding guidelines.

Effective January 1, 2021, the CMS will reduce the payment for high throughput COVID-19 tests, specifically HCPCS U0003 and U0004, to $75 for clinical diagnostic laboratories.  The CMS will pay an additional $25 for a high throughput COVID-19 test if:

  • The test is completed in two calendar days from obtaining the sample
  • The laboratory completes the majority of the COVID-19 tests within two days (not just Medicare) in the previous month
Add-on Codes Required

The CMS approved HCPCS code U0005 as the add-on payment for HCPCS code U0003 or U0004.  The add-on code must be listed separately to indicate the results were completed within two calendar days of the test being obtained.  This payment change is effective for clinical diagnostic laboratories.  The description for HCPCS code U0005 is as follows:

What should your health plan expect regarding high throughput COVID-19 tests after January 1, 2021?*

  • Claims for HCPCS code U0003 or U0004 billed by a clinical diagnostic laboratory with place of service 81 with a CMS reimbursement for $75
  • Claims for HCPCS code U0005 billed as the add on code to indicate high throughput test was completed within the 2-day calendar window with a CMS reimbursement for $25

What should your health plan consider as outlier utilization or unlikely COVID-19 testing after January 1, 2021?

  • High throughput tests billed by physicians
  • Laboratories billing for high throughput tests without prior molecular diagnostic testing claims
  • Laboratories without Compliance level CLIA certification billing for high throughput tests
  • High utilization percentage for the add-on code with high throughput tests by any provider

How does the Codoxo Forensic Platform assist your health plan with identifying emerging risks, trends and outlier claims for COVID-19 high throughput tests?

  • The AI engine and detectors identify patterns, volume and frequency across all peer groups and claims allowing customers to identify, analyze and respond to potential FWA and efficacy issues
  • The Query tool allows users to build custom queries, tailored to your organizational needs

If you are an existing customer, please contact your Customer Success representative or support@codoxo.com for assistance with this topic.  If you would like more information or to setup a demonstration of the Codoxo Forensic Platform, please contact sales@codoxo.com.

*Applicable only to Medicare/Medicare Advantage – refer to your health plan reimbursement policy

HCPCS U0005 Description and Source References

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, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date of specimen collection (list separately in addition to either HCPCS code U0003 or U0004) as described by CMS-2020-01-r2.

References:
  1. CMS News Source: https://www.cms.gov/newsroom/press-releases/cms-changes-medicare-payment-support-faster-covid-19-diagnostic-testing
  2. CMS Document Source: https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf

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