CMS Creates New Code for Over-the-Counter COVID-19 Test

by  Raquel Shumway
Apr 25th, 2022

COVID-19 testing coverage is expanding with a new code which became effective on April 4, 2022. From that date until the end of the COVID-19 public health emergency (PHE), Medicare is conducting a COVID-19 Test demonstration “to find out if Medicare payment for OTC COVID-19 tests will improve access to testing and result in Medicare savings or other program improvements.”

Use the new code, K1034 “Provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared, one test count”, to bill Medicare. Up to 8 over-the-counter (OTC) COVID-19 tests will be covered per calendar month, at no cost to those who are enrolled in Medicare Part B. This includes those who are enrolled in a Medicare Advantage (MA) plan. 

Patients who are enrolled in Medicare Part A only can get OTC COVID-19 tests through other government programs. A free, at-home COVID test can be ordered from one of these two sites: 

• Covidtests.gov
• United States Postal Service (USPS)
• Other Order Options

Click here for a list of eligible providers/suppliers.  

Participation is implied when a Medicare claim for an OTC COVID test is submitted. Because it is voluntary, there is no participation agreement necessary and if you are already enrolled in Medicare and are already providing ambulatory healthcare services, you do not need to complete a new enrollment form. 

NOTE: Those choosing NOT to participate are still allowed to sell OTC COVID-19 tests to all patients.

Medicare will pay for 8 tests per calendar month through the end of the PHE. When a patient receives more than 8, the out-of-pocket cost will be the responsibility of the patient. This cost may be covered by any additional coverage the patient may have. The total of 8 tests per patient applies to one provider or many providers.

The Medicare announcement states (bold added for emphasis):

Use of an ABN is encouraged (not required) before providing an OTC COVID-19 test to a patient. It alerts the patient to the limit of 8 tests and that anything over that amount will be paid by them. Per Medicare, “If you submit a claim for a number of tests that’s more than the 8 per calendar monthly limit, we’ll deny payment. If we deny a claim for this reason, you can bill the patient directly for the excess tests.”

When billing for MA Plan patients, the instructions are a little different than for other types of supplies. Medicare gives the following directions: “... submit claims to Original Medicare through your Medicare Administrative Contractor (MAC). Use your patients’ Medicare Beneficiary Identifiers (MBIs) (not their Medicare Advantage Plan Member IDs) to bill Original Medicare.” Other tips include:

• No physician order or supervision is required.
• Bill for total number of tests used
• Single tests bill 1 unit
• Multiple-test package bill for # of tests included in package
• Use code K1034 (Provision of COVID-19 test, nonprescription self-administered and self-collected use, FDA approved, authorized or cleared, one test count)
• Use standard claim format (1500 Claim Form or 837 format)
  Do NOT use roster bills to bill Medicare for OTC COVID-19 tests
• Claims submitted by patients will be returned.
• If a claim is submitted by a provider and denied, the patient may appeal it.

Medicare further states that:

“We’ll pay you directly when you submit valid claims for eligible Medicare patients who ask for tests and haven’t reached the OTC COVID-19 test quantity limit of 8 tests per calendar month. 

We’ll pay claims in the order we get them. Be sure to submit claims promptly. We’ll only pay claims with dates of services starting on or after April 4, 2022, through the last day of the COVID-19 PHE.”

For further information, click here.