Search For:

The purpose of this memorandum is to inform providers that DMAS fee-for-service (FFS) and all contracted managed care plans will cover one (1) new COVID-19 antigen testing code and two (2) new COVID-19 high throughput testing codes. Further contact information is included at the bottom of this document.

Antigen Testing

The antigen testing code below will be covered with effective dates of service of November 5, 2020 and onwards. Laboratories billing for these codes will need to be CLIA-certified.

• 87426: 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, SARS-CoV-2, COVID-19).  

For members enrolled in the FFS program, DMAS will reimburse providers for COVID-19 antigen testing under the following conditions (additional considerations on antigen testing are described in Appendix A):

• The test has received an Emergency Use Authorization (EUA) granted by the Food and Drug Administration (FDA). COVID-19 antigen tests with EUA are listed at: https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#individual-antigen;
• The purpose of testing is to establish a diagnosis for a patient with symptoms suggestive of COVID-19, and;
  • Diagnostic test results (both positive and negative) were reported to the Virginia Department of Health per federal reporting requirements (for more information, see: https://www.vdh.virginia.gov/clinicians/covid-19-update-for-virginia-7/).

The Center for Medicare and Medicaid Services (CMS) has not yet established a reimbursement rate for COVID-19 antigen tests (CPT 87426). Since DMAS typically benchmarks its laboratory reimbursement rates to 88% of those established for Medicare, the preliminary reimbursement rate for 87426 will be identical to the current DMAS reimbursement rate for CPT 87400 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method): $6.93. DMAS will update its reimbursement rate for CPT 87426 when CMS establishes a reimbursement rate for Medicare. If the updated reimbursement rate differs from the preliminary reimbursement rate of $6.93, DMAS will reprocess any claims paid at the preliminary reimbursement rate.

High Throughput Testing

The high throughput testing codes below will be covered with effective dates of service of November 5, 2020 and onwards. Per guidance issued by the Centers for Medicare and Medicaid Services (CMS): “it is noted that U0003 should identify tests that would otherwise be identified by 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.” (https://www.cms.gov/files/document/cms-2020-01-r.pdf)

• 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.

The reimbursement rate for these codes will be: U0003 = $88; U0004 = $88

For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed below.

Antigen tests for the detection of COVID-19 are generally less sensitive than PCR-based methods, and their clinical performance depends on the circumstances in which they are used.

Please see updated guidance from the Centers for Disease Control (CDC) and Virginia Department of Health (VDH) on when to use and how to interpret the results of COVID-19 antigen tests:

CDC guidance can be accessed here: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-guidelines.html

VDH guidance can be accessed here: https://www.vdh.virginia.gov/coronavirus/health-professionals/testing-laboratory-and-therapeutics/