In a March 1 blog, I reviewed existing Medicare LCDs and coding rules for viral testing (here). On March 5, Vice President Pence defined COVID-19 tests as an "essential health benefit" paid under Medicaid, Medicare, and private plans (here).
Here's the conventional coding for services that don't have a CMS or AMA code yet. Infectious agent DNA/RNA probe detection runs generally from 87471 forward. In a nutshell, for tests for viruses not yet codified by name, payment per test is low and inadequate.
- Options include 87797 (direct probe, per organism), 87798 (amplified probe, per organism), and 87799 (quantitative DNA/RNA probe, per organism.)
- CMS pays $30, $35, and $43 respectively.
All three of these codes are BUNDLED in the hospital outpatient setting such as hospital outpatient clinics and emergency rooms. (They are also bundled if they are tested by a hospital within 3 days before an inpatient admission). So in most settings, for Medicare patients being seen in an ER or hospital outpatient clinic, there is no separate or add-on payment for COVID-19 testing (under a simple reading of existing rules). The hospital eats the testing cost.
CMS represents this "bundled" status by giving the infectious disease codes classification "Q4" in the hospital outpatient coding system:
|Hospital outpatient codes: Q4 = bundled|
In a cloud database, CMS provides information on all labs and physicians paid in Part B for these codes in CY2017 (here). Searching for 87797, 98, 99, yields 467 data lines.
For all these codes together, there were 844,400 services for $35,069,906.
For 87797, there were 3,549 services for $96,556.
For 87798, amplified probe, there were 683,151 services for $25,822,643.
For 87799, quantitative, there were 157,710 services for $9,150,707.
To Amplify on Payments for 87798 (ha ha inside joke)
Interestingly, the the highest paid labs for 87798 (amplified probe) in Part Bwere not the top several highest-paid labs overall. The highest-volume labs for 87798 were CAP Dx (Irvine, CA) at 26%, Bakotic Pathology (Alpharetta, CA) at 13%; Genova Dx ((Duluth GA) at 9%, and Labcorp (Burlington NC) at 6%. Excel in cloud here.
|click to enlarge|
Nerd note. In the first chart, where most virology codes are "bundled, Q4," I have no idea why code 87800 is not bundled (is status A) and I've asked different staff at CMS if there is any explanation.