Nov. 11, 2021

BlueCross BlueShield of South Carolina and BlueChoice^® HealthPlan continue to monitor the status of the COVID-19 virus to ensure our provider community remains abreast of any changes in policy or procedure related to the care of your patients, our members.

The following code set is recognized by CMS as valid services for COVID-19 testing.

U0003 – 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

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 two calendar days from date and time of specimen collection.

Regarding the reimbursement of U0005, although the Centers for Medicare & Medicaid Services (CMS) as a payer elected to cover U0005, commercial payers are not required to align with this coverage.

CMS’s decision to reimburse U0005 has several factors to consider:

1. Reimbursement for COVID-19 diagnostic tests (U0003 or U0004) run on high-throughput technology was lowered to $75 from $100.
2. Additional reimbursement for the service U0005 applies if:
   • The test is completed in two calendar days or less from the date of specimen collection.
   • The majority of the provider’s COVID-19 diagnostic tests (U0003 or U0004) performed using high-throughput technology in the previous calendar month were completed in two calendar days or less for all their patients.

To ensure proper timeframes for reimbursement are met, CMS can perform audits of the laboratory’s records to support the billing of U0005.  If the above criteria are met, CMS will make an additional $25 add-on payment for U0005, bringing the total reimbursement of U0003 or U0004 and U0005 to $100. 

For laboratories that do not meet the criteria, CMS will only reimburse $75 for U0003 or U0004.

BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan, on the other hand, did not elect to lower the amount of the diagnostic tests, and both plans continue to reimburse codes U0003 or U0004 at $100.  Therefore, no additional payment would be warranted for U0005.

If you have any questions regarding this bulletin, please contact Provider Education using the Provider Education Contact Form located on www.SouthCarolinaBlues.com or www.BlueChoiceSC.com.