Primary Care Coding Alert

Question: Some local hospitals are referring patients to us for COVID-19 testing prior to a non-emergent hospital procedure. We see these patients in our office to perform the swab. My question is: how do we code these encounters? Do we use Z01.818 or Z11.59, or do we need to have the primary diagnosis for the procedure for the reason they are being tested? Also, what code do we use for the specimen collection since we have to use personal protective equipment (PPE) to obtain it?

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Answer: In situations like these, the American Medical Association (AMA) directs you use either 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional …) or 99000 (Handling and/or conveyance of specimen for transfer from the office to a laboratory) if the code requirements are met for the swab collection itself and if you are not reporting some other evaluation and management (E/M) code for the encounter (See www.ama-assn.org/system/files/2020-05/cpt-reporting-covid-19-testing.pdf).

The 99000 would only be appropriate if there is work involved for your office in preparing the specimen, or your office incurs expenses for the handling and/or transportation (for example, you are being charged for the courier picking up the specimen to be delivered to the lab). The code is really for preparing and shipping the sample, and not simply for the work obtaining the swab. In other words, the code choice depends on the work your office is doing to get the sample to the lab (99000) versus the work you’re doing getting the sample from the patient (99211).

In your circumstances, the 99211 E/M service is probably the best choice. But both private insurances and public payers such as Medicare and Medicaid may have their own reporting requirements for the service, so you would do well to check and see what their position is.

The diagnosis code to go with the procedure will depend on the circumstances of the patient. The Centers for Disease Control and Prevention (CDC) is saying that “for asymptomatic individuals who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative, assign code Z11.59 [Encounter for screening for other viral diseases].” Their guidelines also instruct you to use Z03.818 (Encounter for observation for suspected exposure to other biological agents ruled out) “for cases where there is a concern about a possible exposure to COVID-19, but this is ruled out after evaluation” (See www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf).

However, your context is different, as the purpose of collecting the swab is not just for obtaining a specimen for testing but also for clearing the patient for a procedure. In this case, Z01.812 (Encounter for preprocedural laboratory examination) rather than Z01.818 (Encounter for other preprocedural examination) may be more appropriate. In any case, Z11.59 is probably best, as it is consistent with CDC guidelines.

There is no reason to provide an ICD-10 code for the reason the patient is having the procedure at the hospital; however, there would probably be no harm in including it as a secondary code. But, as always, checking with your payer before using any of these codes would be a good idea, especially as they may not be up to speed with the CDC’s current rulings.