Very Brief Blog: No, Virginia, Medicare Might Not Pay for COVID-19 Testing Separately (See Outpatient Billing/Bundling Rules)

Note, Update March 6:  CMS announced on March 5 it would pay for new U-codes U-0001, U-0002, separately in the hospital outpatient setting details here.


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

2017 Utilization of 87797, '98, '99 in CY2017 Part B Data

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

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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.