Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY: Covid 19 Testing reimbursement policy update 06/01/22

If your office accepts emblemhealth members and provides COVID-19 testing services, then this blog post is for you!

COVID-19 Tests:

There are 3 main types of tests for COVD-19 (SARS-CoV-2) virus- diagnostic (viral), antigent test and serologic test (antibody.

A diagnostic (molecular and antigen tests tells if you likely have a current infection, by looking for parts of the virus itself in samples taken from an individual’s respiratory system secretion (eg. nasal swab).

A serologic, or anitybody test tells you if you have had a previous infection of COVID-19 by looking at the antibody responses in the blood sample. (In general a serologic test cannot be used for a diagnostic purposes. Antibodies can be detected in individuals that had a distant infection of the virus)


The following policy applies to Commercial, Medicare and Medicaid lines of business: via EmblemHealth Policy#: RPC20210016

Per the CDC, “Cliniciansshould use their judgment to determine if a patient hassigns orsymptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough) but some infected patients may present with other symptoms as well.”
▪ Symptomatic individual suspected of having COVID-19.
▪ Testing of asymptomatic patients used as part of a pre-surgical or facility pre-admission screening,
prior to an immunosuppressive procedure, or when a patient is admitted to a Skilled Nursing
Facility in accordance with CMS and CDC testing guidelines.
▪ Known or suspected prolonged, close contact, with an individual with a laboratory confirmed case
of COVID-19 as defined by CDC guidelines.
▪ Coronavirus COVID-19 (SARS-CoV-2) respiratory panel (up to 5 respiratory pathogens) test when
member has signs and symptoms of COVID-19.


SARS-CoV-2 Serology Testing
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) serology (antibody) testing may beconsidered a covered service when the following criteria are met:
▪ An individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, OR
• A licensed or authorized health care provider refers an individual for a COVID-19
diagnostic test. AND
▪ FDA approved or cleared or Emergency Use Authorization (EUA) AND
▪ Performed by a CLIA-accredited high or medium-complexity laboratory (per test Instructions for Use) AND
One of the following three conditions is present:
▪ Results of a molecular or antigen test is non diagnostic for COVID-19 and the results of the test will be used to aid in the diagnosis of a condition related to COVID-19 infection (e.g., Multisystem Inflammatory Syndrome [MIS]). OR
▪ Used as a method to support the clinical assessment of acute COVID-19 illness for persons who are being tested 3–4 weeks after illness onset, in addition to recommended direct detection methods such as polymerase chain reaction (PCR). OR
▪ Used as a method to help establish a clinical picture when patients have late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.


Coding/Billing Information:
Effective 6/1/2022 – EmblemHealth and ConnectiCare will amend the billing
instructions to align with CMS’ instructions on how to bill for COVID-19 test related
services. The plan will require the use of modifier CS when identifying services that
are related to the need determination for a COVID-19 test.

Partial List of CPT/HCPCS codes:

*NY Medicaid covered codes may differ and follow NYS guidelines
CPT/HCPCS Description
U0001* CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
U0002(QW) 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes(includes all targets), non-CDC
U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 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 2 calendar days from date and time of specimen collection.(List separately in addition to either HCPCS code U0003 or
U0004)
0224U -Antibody, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID19]),includes titer(s), when performed
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 (Xpert® Xpress SARSCoV-2/Flu/RSV (SARS-CoV-2 & Flu Targets only), Cepheid)
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 (Xpert® Xpress SARSCoV-2/Flu/RSV(all targets), Cepheid)
86328- Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

For a complete list of codes, please click here for the complete reimbursement policy.


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Posted in BCBS (Various States), Training, Updates

Anthem BCBS California: administration of drug Spravato-proper medical billing and coding.

If you are a physician that accepts patients with Anthem BCBS plans then this blog post is for you.


Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression.  Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.


There are 2 ways physicians can code the administration of this drug:

Option 1 (Professional Services) – The physician buys the drug and administers it to the patient as well as provides the observation services- Anthem BCBS of California will NOT cover the drug itself or the post administration observation. Instead physicians should use the 2 following codes:

HCPCS CodeDescription
G2082Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
G2083Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
via Anthem BCBS California

Option 1 Outpatient Hospital – the facility is allowed to bill codes G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. Anthem BCBS of California will not reimburse a separate professional claim with code G2082 and G2083.

Option 2: The drug is obtained through a pharmacy. Pharmacy bills the code S0013 – Esketamine, nasal spray, 1 mg. 


Post-administration observation: if physician falls into the option 2 category then the physician is allowed to bill the following code:

CPT CodesDescription
99202 – 99205Office or other outpatient visit for the evaluation and management of a new patient
99212 – 99215Office or other outpatient visit for the evaluation and management of an established patient
99417Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
via Anthem BCBS California

In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding.  Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.


Please remember that codes exist but that doesn’t mean that all of them will be reimbursed. In order to reduce denials and get your claims paid please follow the reimbursement policy of a specific Insurance Payer.

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Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth/Connecticare: Telehealth Reimbursement Policy Update for 2022

If you are a provider that accepts patients with EmblemHealth and/or Connecticare Insurance this blog post is for you!

This policy applies to Emblemhealth/Connecticare Commercial, Medicare and Medicaid Members.


Effective 01/01/2022- EmblemHealth/Connecticare has updated their telehealth policy. The following update was added:


Effective 06/01/2022- changes effect modifiers:

Want to learn more? Please click here to see the whole telehealth policy.


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