For commercial members non-facility telemedicine claims must use POS 02 with the GT or 95 modifier. Fee schedules have been updated so claims with approved telemedicine CPT codes and modifiers with POS 02 will be reimbursed at the same rate as an equal office visit. For example, a telemedicine service 99213 GT with POS 02 will reimburse the same as a face-to-face in-office visit 99213. Urgent Care Centers should continue to use POS 20. All other facilities should continue to use their respective POS; CPTs and the telemedicine modifiers must be noted on the UB-04 and HCFA 1500 forms as the Rev Code will not be sufficient.

For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the 95 modifier indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate.

Aetna’s telemedicine policy is available to providers on the Availity provider portal.

Reporting codes related to COVID-19 include:

ICD-10 Reporting Codes

• U07.1 - COVID-19
• J12.82 - Pneumonia due to coronavirus disease 2019
• M35.81 - Multisystem inflammatory syndrome (MIS)
• M35.89 - Other specified systemic involvement of connective tissue
• Z11.52 - Encounter for screening for COVID-19
• Z20.822 - Contact with and (suspected) exposure to COVID-19

Exposure to COVID-19

• Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out). Used for cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation.
• Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases). Used for cases where there is an actual exposure to someone who is confirmed to have COVID-19.

Aetna is complying with the CMS coding guidelines for COVID-19 lab testing. The following codes should be used for COVID-19 testing for commercial and Medicare plans:

• U0001 - 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel should be used when specimens are sent to the CDC and CDC-approved local/state health department laboratories.
• U0002 - 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC should be used when specimens are sent to commercial laboratories, e.g. Quest or LabCorp, and not to the CDC or CDC-approved local/state health department laboratories.
• U0003 - 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 as described by CMS-2020-01-R.
• U0004 - 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 as described by CMS-2020-01-R.
• U0005* - 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 two calendar days from date and time of specimen collection. (List separately in addition to either HCPCS code U0003 or U0004).
• 0202U** - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
• 0223U** - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
• 0225U** - Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected.
• 0226U - Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum.
• 0240U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected.
• 0241U - Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected.
• 86413 - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative.
• 87426 - Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (e.g. SARS-CoV, SARS-CoV-2 [COVID-19]).
• 87635 - 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. Use of code 87635 will help the labs to efficiently report and track testing services related to SARS-CoV-2 and will streamline the reporting and reimbursement for this test in the US.
• 87636 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique.
• 87637 - Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique.
• 87811 - Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 86328 - Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 86408 - Long Descriptor: Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen.
• 86409 - Long Descriptor: Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer.
• 86769 - Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
• 0224U - Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed.

*As announced by CMS, starting January 1, 2021, Medicare will make an additional $25 add-on payment to laboratories for a COVID-19 diagnostic test run on high throughput technology if the laboratory: a) completes the test in two calendar days or less, and b) completes the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month. Laboratories that complete a majority of COVID-19 diagnostic tests run on high throughput technology within two days will be paid $100 per test by Medicare, while laboratories that take longer will receive $75 per test. CMS established these requirements to support faster high throughput COVID-19 diagnostic testing and to ensure all patients (not just Medicare patients) benefit from faster testing. These actions will be implemented under the amended Administrative Ruling (CMS-2020-1-R2) and coding instructions for the $25 add-on payment (HCPCS code U0005).

**Specific to COVID-19, we will not reimburse for multitarget tests for the screening for COVID-19 such as codes 0202U, 0223U, 0225U. There are more specific tests to screen for this condition. These multitargeted codes could be allowed for non-COVID-19 specific testing. Member cost-sharing will be determined based on the type of claim submission.

Learn more about CMS Changes Medicare Payment to Support Faster COVID-19 Diagnostic Testing or for additional information and future updates, visit the CMS newsroom.

Providers should bill for the COVID-19 swab collection using one of these codes:

• Use code 99211 - Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional.
• Use code G2023 - Specimen collection for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source*
• Use code G2024 - Specimen collection for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source*
• Use code C9803, - Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])*

Visit the CMS website for COVID-19 FAQs on Medicare fee-for-service (FFS) billing.
 

* Coverage is limited to specific places of service.

Telemedicine will be covered within the capitation agreement, similar to an in-office visit.

Aetna will cover appropriate evaluation and management codes with a wellness diagnosis for those aspects of the visit done via telehealth. Preventative visit codes should be reserved for such time when routine in-office visits resume and the remaining parts of the well visit can be completed. Both services will be fully reimbursed, and the patient will not incur a cost share.

Providers should bill for the administration of monoclonal antibody therapies using one of these codes:

• M0239 - Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring
• M0243 - Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring
• M0245 - Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring

Behavioral Health telemedicine codes (PDF)

In addition to the appropriate oral evaluation code, (for example D0140) one of the following codes should be reported:

• D9995 tele-dentistry – synchronous; real-time encounter. Reported in addition to other procedures (e.g. diagnostic) delivered to the patient on the date of service.
• D9996 tele-dentistry – asynchronous; information stored and forwarded to dentist for subsequent review. Reported in addition to other procedures (e.g. diagnostic) delivered to the patient on the date of service.

The submission of D9995 or D9996 is purely informational. These codes indicate to us that the evaluation was performed via tele-dentistry, the way a code modifier is used on a medical claim. The code that will be reimbursed is the oral evaluation code.

For PPO plans: All emergency exams will be covered at 100% of the providers negotiated fee. Out-of-network services will be paid at the in-network level. Palliative treatment will be paid at the members benefit level.

For DMO plans: Will follow our standard DMO handling and normal protocols. Referrals are not required for emergency care. Tele-dentistry codes D9995 and D9996 will not be reimbursed. Those codes were not developed for reimbursement; they were created to be used as code modifiers, so that dentists have a way to report that an oral evaluation was performed via tele-dentistry.

We will not require any additional proof of services. The claim should list the services performed using a valid CDT code.

ADA guide to understanding and documenting teledentistry events (PDF)

If a dentist is seeing a patient in their office, they should submit their office address as they normally would. If the encounter is entirely virtual, then they should follow CMS guidance, which is to enter the place of service code, “02” (telehealth), into Box 38 on the ADA dental claim form.

In-network providers have a contracted fee schedule for all CDT codes including oral evaluations. There should not be a charge reported for codes D9995 and D9996. Those codes were not developed for reimbursement; they were created to be used as code modifiers, so that dentists have a way to report that an oral evaluation was performed via tele-dentistry.

We have not established an end date at this point but will reassess this policy as needed.

Any oral evaluation covered under Aetna dental plans and performed via tele-dentistry will be reimbursed the same as if it was performed in a traditional practice setting.

Dentists can find all policies and clinical bulletins by visiting the Aetna Dental website.

Aetna suspended the 2% sequestration reduction in payments made to providers, to support them during the COVID-19 pandemic. This applied to claims reimbursements to providers in fee-for-service arrangements in Aetna Medicare Advantage plans. The suspension aligned with the current CARES Act legislation (H.R. 1868-117^th Congress (2021-2022)) requiring all health plans to suspend the 2% sequestration reduction in payments from May 1, 2020 to December 31, 2021.

CARES Act - SEC. 3709. Adjustment of sequestration

All claims that are based on Medicare payment (Medicare and Medicaid) with dates of service May 1, 2020 through December 31, 2021 will no longer apply the 2% reduction and will be in line with the CARES Act legislation.

The 2% reduction will automatically be removed for those claims where sequestration is applying.

We will evaluate any new legislation and make related policy decisions at the time it occurs.

We will pay providers according to the terms of their participation agreement. For providers who treat Medicare Advantage members and whose contracted reimbursement is based upon CMS IPPS reimbursement methodology, we will apply the increase, as appropriate, for discharges of individuals diagnosed with COVID-19 during the emergency period.

For admissions on or after September 1, 2020 claims eligible for the 20% increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test within 14 days of an inpatient admission documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e. molecular or antigen), consistent with CDC guidelines and can be manually entered into the patient’s medical record.

CMS may conduct post-payment medical review to confirm the presence of a positive COVID-19 laboratory test and, if no such test is contained in the medical record, the additional payment resulting from the 20% increase in the MS-DRG relative weight will be recouped.

A hospital that diagnoses a patient with COVID-19 but does not have evidence of a positive test result can decline, at the time of claim submission, the additional payment of the 20% increase in the MS-DRG relative weight to avoid the repayment.

To notify your MAC when there is no evidence of a positive laboratory test documented in the patient’s medical record, enter a Billing Note NTE02 “No Pos Test” on the electronic claim 837I or a remark “No Pos Test” on a paper claim.

For out-of-network providers who treat Medicare Advantage members, we will comply with CMS requirements and apply the increase, as appropriate, for discharges of individuals diagnosed with COVID-19 during the emergency period. Providers are required to comply with CMS coding and billing requirements. For a provider who treats commercial or Medicaid members, we will pay for covered services in accordance with the member’s health plan benefits and applicable laws and regulations.

Effective dates for the COVID-19 add-in payment depend on the codes used and the date of patient discharge. Effective dates apply as follows:

• B97.29 (Other coronavirus as the cause of diseases classified elsewhere) for discharges occurring on or after January 27, 2020, and on or before March 31, 2020.
• U07.1 (COVID-19) for discharges occurring on or after April 1, 2020, through the duration of the COVID-19 public health emergency period.

Due to a delay in CMS releasing necessary information related to the increase in this weighting factor, and to accelerate payment to providers, we processed inpatient claims according to available information at the time. We will be automatically reprocessing the impacted claims. No action is required by providers to initiate the reprocessing.