New York State Medicaid Billing Guidance for COVID-19 Testing, Specimen Collection and Monoclonal Antibody Infusions

  • Guidance is also available in Portable Document Format (PDF)

Updated: 4/23/2021

UPDATES are highlighted in YELLOW

The services in this guidance document are currently reimbursable by New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans. The fees* below are specific to Medicaid FFS. For individuals enrolled in MMC, providers should check with the individual´s plan for implementation details and billing guidance. Providers are reminded COVID-19 tests performed 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 Lab.

* The fees and effect dates below are current as of April 2021. Providers should periodically check their respective fee schedules in eMedNY for updates. Complexity levels are available here. Tests with EUA

Please note: The COVID-19 test codes with highlighted effective dates have been backdated. Previously denied claims with a "code not active" denial code will be reprocessed automatically. Eligible claims for periods between the highlighted effective date and January 1, 2021 that are submitted within 30 days of this notice will be processed. COVID-19 test codes not outlined in this guidance are not covered.

Molecular/PCR Tests:

  • "87635" (effective 3/13/2020) - 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. FFS fee =$51.31
  • "U0002" (effective 3/13/2020) - 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 utilize 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 200 specimens a day.

It is noted that U0003 should identify tests that would otherwise be identified by Current Procedural Terminology (CPT) code 87635 but for being performed with these high throughput technologies. It is further noted that U0004 should identify tests that would otherwise be identified by U0002 but for being performed with these high throughput technologies. Finally, it is noted that neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.

  • "U0003" (effective 4/14/2020) - 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. FFS fee = $100 (until 12/31/2020), $75 (beginning 01/01/2021)
  • "U0004" (effective 4/14/2020) - 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

In accordance with CMS, the fees for high throughput tests will be reduced to $75 effective 01/01/2021. For dates of service on or after 01/01/2021, U0005 may be billed as an add on code, when appropriate.

  • "U0005" (effective 01/01/2021) -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 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. FFS fee = $25

COVID-19 diagnostic tests with "at home" sample collection are considered eligible for reimbursement when the criteria outlined in this guidance are met and the test is processed in a New York State approved laboratory. Respiratory panel tests and tests not represented in this guidance are not covered.

Antigen Test:

  • "87426" (effective 06/25/2020) -Infectious agent antigen detection by immunoassay technique, (e.g., 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-2, SARS-CoV-2 [COVID-19]). FFS fee = $45.23
  • "87811" (effective 10/06/2020) - Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]). FFS fee = $41.38

Multiplex Tests:

  • "87428" (effective 11/10/2020) - Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV-2, SARS-CoV-2 [COVID-19]) and influenza virus types a and b. FFS fee = $73.49
  • "87636" (effective 10/06/2020) - 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. FFS fee = $142.63

Antibody Tests:

Please see the following link for information on antibody testing for NYS residents.

  • "86328" (effective 4/10/2020) - 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]). FFS fee = $45.23
  • "86769" (effective 4/10/2020) - Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]). FFS fee = $42.13

Specimen Collection (effective 05/22/2020): 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/Clinics billing for other primary procedures for the same patient on the same day should not bill for specimen collection. For more information please see the chart below.

Code Description Practitioner/Clinic (Non-FQHC) Reimbursement FQHC Reimbursement
G2023 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) (Coronavirus disease [COVID-19]) $23.46 Physician/PA/NP/Midwife: bill rate code 4012 when specimen collection only is provided. Offsite visit rate ($64.97 upstate/$72.73 downstate) will be paid.

Physician/PA/NP/Midwife: bill rate code 4013 when specimen collection and E&M are provided. Full PPS rate will be paid.

RN/LPN: bill Procedure Code G2023 (ordered ambulatory) for specimen collection only. A fee of $23.46 will be paid.

All FQHC services in this chart are eligible for wrap payments.

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).

Skilled Nursing Facilities services are paid at a daily rate; therefore, separate reimbursement is not available.

Certified Home Health Agencies (CHHAs) should perform specimen collection as part of nursing visits when ordered for existing clients who receive nursing services.

CHHA specimen collection for homebound patients who do not recieve nursing services is eligible for reimbursement on or after 11/01/2020. Please see the chart below for details.

Rate Codes Used for CHHAs Only Descriptions CHHA Patient Receiving Nursing Services CHHA Patient Receiving Personal Care Services NON-CHHA Homebound Patient MLTC Patient Homebound Patient
4921 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from a homebound*** individual on behalf of a home health agency, any specimen source(s). Reimburses $25.46. For CHHA use only. X
Do not bill for specimen collection or travel. This should be done as part of a nurse visit and is included in the CHHA rate.

CHHAs providing nursing staff to collect a specimen from their patient who only receives lower level services may bill rate code "4921" and rate code "4922" (travel each way) if specimen collection is the only service performed.

CHHAs providing specimen collection to a homebound individual who is not a CHHA patient may bill rate code "4921" and rate code "4922" (travel each way) if specimen collection is the only service performed.

CHHAs providing specimen collection for homebound patients may bill rate code "4921" and rate code "4922" (travel each way) to Medicaid if specimen collection is the only service performed.
4922 Travel for COVID-19 specimen collection. Reimburses $9.35 each way. For CHHA use only. When seeing multiple patients in the same location** only bill 1 trip charge for the first Medicaid member visit.

** The same location is defined as a vehicle is not necessary to travel between visits.

  1. *** Patients are considered "homebound" if they meet these two criteria. Patients either need supportive devices such as crutches, canes, wheelchairs, and walkers; special transportation; or help from someone else in order to leave their home because of illness or injury OR have a condition that makes leaving the home medically inadvisable, and
  2. There must exist a normal inability to leave home; and leaving home must require a considerable and taxing effort.

If specimen collection occurs during a home visit where other scheduled services are being provided, a specimen collection fee and travel expense cannot be billed. Payment is included in the CHHA´s per diem payment. CHHAs may bill for members who only receive lower level services when a nurse is sent to collect the specimen (see chart above). This includes homebound patients enrolled in Managed Long-Term Care. COVID specimen collection should not be billed to Medicaid when a home health visit is covered by Medicare (either episodic or Low Utilization Payment Adjustment (LUPA)/FFS payment).

Providers who are already receiving payment, from another source, for COVID-19 testing, specimen collection, or monoclonal antibody infusion should not bill Medicaid. For additional testing guidance from the CDC and Wadsworth Center please see the following links:

For additional testing guidance from the CDC and Wadsworth Center please see the following links:

Monoclonal Antibody COVID-19 Infusions

Payment Allowances and Effective Dates for COVID-19 Monoclonal Antibodies and their Administration
Code Labeler Name Vaccine/Procedure Name Payment Allowances Effective Date
Q0239 Eli Lilly Injection, bamlanivimab, 700 mg $0.00 11/10/2020
- 4/16/2021* EUA REVOKED
M0239 Eli Lilly Intravenous infusion, bamlanivimab, includes infusion and post administration monitoring $309.60 11/10/2020
- 4/16/2021* EUA REVOKED
Q0243 Regeneron Injection, casirivimab and imdevimab, 2400 mg $0.00 11/21/2020
M0243 Regeneron Intravenous infusion, casirivimab and imdevimab, includes infusion and post administration monitoring $309.60 11/21/2020
M0239 Eli Lilly Intravenous infusion, bamlanivimab, includes infusion and post administration monitoring $0.00 2/9/2021
M0239 Eli Lilly Intravenous infusion, bamlanivimab, includes infusion and post administration monitoring $309.60 2/9/2021

Monoclonal antibody infusion is reimbursable when provided in a hospital outpatient department or physician´s office. Providers should bill the codes outlined in this guidance via the ordered ambulatory and/or physician fee schedule. The payment allowances for the above infusion administration codes include all costs for any saline, any other fluid, and/or any other drug used for the infusion and any post-infusion patient monitoring.

Additional information on the COVID-19 Monoclonal Antibodies and their administration can be found here.

Questions:

  • Medicaid FFS coverage and policy questions should be directed to the Office of Health Insurance Programs, Division of Program Development and Management, at (518) 473-2160 or FFSMedicaidPolicy@health.ny.gov.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC plan.
  • FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.