New York State Medicaid billing guidance for COVID-19 testing, specimen collection, and therapeutics

This guidance was published in 2020 by the New York State Department of Health. It provides details about billing for COVID-19 testing, specimen collection, and provided therapeutics. When submitting claims, ensure to follow the guidance below to avoid claim recoveries. 

Laboratory testing and specimen collection

Providers are reminded that Coronavirus (COVID-19) tests must be Food and Drug Administration (FDA)-approved or granted Emergency Use Authorization (EUA) through the FDA and in agreement with the level of complexity assigned by Wadsworth Laboratory to be eligible for reimbursement. COVID-19 test coverage for diagnostic and screening, including administration, must be consistent with the recommendations of the Centers for Disease Control and Prevention (CDC). 

*The fees and effective dates below are current as of December 2021. Providers should periodically check their respective fee schedules in eMedNY for updates through the eMedNY Provider Manuals web page. Complexity levels are available on the CDC Clinical Laboratory Improvement Amendments (CLIA) Test Complexities web page. Tests with EUA can be found on the FDA’s Emergency Use Authorizations for Medical Devices web page. 

Please note: COVID-19 test codes not outlined in this guidance are not covered. 

Individuals with signs or symptoms of COVID-19 should have diagnostic testing.

The CDC also recommends testing for the following individuals listed on the CDC Overview of Testing for SARS-CoV-2, the virus that causes COVID-19 web page. Providers are reminded that, "all persons being tested, regardless of results, should receive counseling on the continuation of risk reduction behaviors that help prevent the transmission of SARS-CoV-2 (for example, wearing masks, physical distancing, and avoiding crowds and poorly ventilated spaces)" per CDC guidance. Additional information regarding risk reduction behaviors is available on the CDC COVID-19 Protect Yourself web page. 

Providers who are already receiving payment from another source for COVID-19 testing, specimen collection, or monoclonal antibody infusion are not eligible for reimbursement from Medicaid for those tests, specimen collections, or infusions. 

Reminder

Providers are prohibited from charging Medicaid members a co-payment or any cost sharing responsibility for specimen collection or testing to diagnose or screen for COVID-19, or for monoclonal antibody infusions to treat a SARS-CoV-2 infection. Check the emergency indicator box on claims submissions to waive cost sharing for these services. 

Home-based testing

COVID-19 diagnostic tests with at-home sample collection are eligible for reimbursement when the criteria outlined in this guidance are met and the test is processed in a New York State (NYS)-approved laboratory. Additionally, over-the-counter (OTC) FDA-authorized COVID-19 diagnostic and screening tests that provide at-home results are eligible for reimbursement during the public health emergency (PHE). For details on coverage of point-of-care tests with at-home results and no member cost sharing, please refer to the New York State (NYS) Medicaid Pharmacy Policy and Billing Guidance for At Home COVID-19 Testing. 

Molecular/polymerase chain reaction (pcr) tests:

• 87635 (effective March 13, 2020) — Infectious agent detection by nucleic acid deoxyribonucleic acid (DNA) or ribonucleic acid (RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19), amplified probe technique: 
  • FFS fee = $51.30
• U0002 (effective March 13, 2020) — 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCov (COVID-19), any technique, multiple types, or subtypes (includes all targets), non-CDC:
  •  FFS fee = $51.31 

High throughput tests

These tests use highly sophisticated throughput machines, which require more intensive technician training (to ensure the role of extremely skilled personnel) and more time intensive processes (to assure quality). A high throughput technology uses a platform that employs automated processing of more than two hundred specimens a day. 

It is noted throughout the CMS-Ruling 2020-1-R document, that U0003 should identify tests that would otherwise be identified by CPT ^® code 87635 but for being performed with these high throughput technologies. U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies. Additionally, neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies:

• U0003 (effective April 14, 2020) — infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R:
  • FFS fee = $100 (until December 31, 2020), $75 (as of January 1, 2021)
• U0004 (effective April 14, 2020) — 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:
  • FFS fee = $100 (until December 31, 2020), $75 (as of January 1, 2021) 

In accordance with CMS, the fees for high throughput tests were reduced to $75 effective January 1, 2021. For dates of service on or after January 1, 2021, U0005 may be billed as an add on code, when appropriate:

• U0005 (effective January 1, 2021) — 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 of specimen collection (List separately in addition to either HCPCS code U0003 or U0004) as described by CMS-2020-01-R2.
  • FFS fee = $25 

Antigen tests:

• 87426 (effective June 25, 2020) — Infectious agent antigen detection by immunoassay technique, (for example, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method); severe acute respiratory syndrome coronavirus (for example, SARS-CoV-2, SARS-CoV-2 COVID-19):
  • FFS fee = $45.23
• 87811 (effective October 6, 2020) — Infectious agent antigen detection by immunoassay with direct optical (in other words, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19):
  • FFS fee = $41.38 

Multiplex tests:

• 87428 (effective November 10, 2020) — Infectious agent antigen detection by immunoassay technique, (for example, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay (FIA), immunochemiluminometric assay (IMCA) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (for example, SARS-CoV-2, SARS-CoV-2 COVID-19) and influenza virus types a and b:
  • FFS fee = $30.94
• 87636 (effective October 6, 2020) — Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19) and influenza virus types a and b, multiplex amplified probe technique:
  • FFS fee = $142.63
• 87637 (effective December 1, 2021) — 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:
  • FFS fee = $142.63 

Antibody tests

Please refer to the following web page for information on antibody testing for NYS residents through the FDA: "Antibody Testing Is Not Currently Recommended to Assess Immunity After COVID-19 Vaccination: FDA Safety Communication:”

• 86328 (effective April 10, 2020) — Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (for example, reagent strip), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19):
  • FFS fee = $45.23
• 86769 (effective April 10, 2020) — Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19):
  • FFS fee = $42.13 

Specimen Collection (effective May 22, 2020): During the period of the emergency, separate Medicaid reimbursement is available for specimen collection when this is the only service being performed. Providers billing for reimbursement of one of the above tests should not bill separately for specimen collection or report. These specimen collection components are included in reimbursement for the test. Providers and clinics billing for other primary procedures for the same patient on the same day should not bill for specimen collection. For more information, please refer to the table below. 

Clinics should bill the codes outlined in this guidance via the ordered ambulatory fee schedule. The COVID-19 test and specimen collection codes are not payable under ambulatory patient groups (APGs).

For additional details, please refer to the state guidance: COVID-19 Guidance for Medicaid Providers (ny.gov).