Coding Scenario: Coding for In-person Visits
In-person Office Visits
Note: These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments.
How do I code for an in-person office visit for COVID-19-related care?
| Aetna | Anthem* | Cigna | Humana |
UHC |
Medicare | |
|---|---|---|---|---|---|---|
| CPT Codes: 99201-99205, 99211-99215 | ||||||
Place of Service (POS) |
Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) | Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) |
Modifier |
The AAFP is seeking additional information. |
-CS *Must use appropriate ICD-10 code (Z03.818 or Z20.828) |
-CS |
-CS |
-CS |
|
Cost-share waiver |
Yes |
Yes |
Yes |
Yes. |
Yes |
Yes |
Cover cost-share |
Yes |
Yes |
Yes. |
Yes |
Yes |
|
*Anthem's policies vary by state; contact your provider-relations representative.
How do I code for an in-person office visit for non-COVID-19-related care?
| Aetna | Anthem | Cigna | Humana |
UHC |
Medicare | |
|---|---|---|---|---|---|---|
| CPT Codes: 99201-99205, 99211-99215 | ||||||
Place of Service (POS) |
Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) | Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) |
Use POS used for typical services (e.g., POS 11 – Office) |
Modifier |
None |
None |
None |
None |
None |
None |
Cost-share waiver |
No |
No |
No |
No |
Yes* |
No |
Cover cost-share |
N/A |
N/A |
N/A |
N/A |
Yes* |
N/A |
*Applies to Medicare Advantage members only
In-person Visit Scenario Notes
Medicare and most national payers will cover pay the full contracted/allowable amount when cost-sharing is waived. The “CS” modifier is required to trigger full payment of the full allowed amount. Claims missing the “CS” modifier may not be paid at the full allowed amount.
COVID-related services include:
- COVID-19 Testing
- An in vitro diagnostic test for the detection of SARS-CoV-2 or the diagnosis of COVID-19. The test must be approved, or the developer has requested or intends to request emergency use authorization under the Federal Food, Drug, and Cosmetic Act;
- a test that is developed in and authorized by a state that has notified the secretary of Health and Human Services (HHS) of its intention to review tests intended to diagnose COVID-19; or
- other tests the secretary of HHS determines appropriate in guidance.
- Items and services furnished to an individual through office visits (in-person and telehealth), urgent care center visits, and emergency room visits that result in an order for or administration of a COVID-test. Items and services must be related to the furnishing or administration of the test or to the evaluation of the patient for the purposes of determining the need for a COVID-19 test.
COVID-19-related services should be assigned the appropriate COVID-19 ICD-10 diagnosis code. Coding guidance can be found on the CDC website. Cost-sharing waivers may not be applied to claims that do not include an appropriate COVID-19 ICD-10 diagnosis code.
Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends contacting your provider-relations representatives or Medicare Administrative Contractors to verify policies. The Center for Connected Health Policy is tracking COVID-19-related state actions.