Starting April 4, and through the end of the COVID-19 public health emergency (PHE), Medicare covers and pays for OTC COVID-19 tests at no cost to people with Medicare Part B, including those with Medicare Advantage (MA) plans. In addition to helping prevent the spread of COVID-19, the goal of this demonstration is 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.
Each eligible Medicare patient can get up to eight tests per calendar month until the PHE ends. Eligible Medicare patients will get these tests at no cost, and their annual deductible, coinsurance, and copayment don’t apply. Medicare won’t pay for more than eight OTC tests in a month. If a patient gets more than eight tests in a calendar month, they may pay out-of-pocket for the extra tests unless they have additional health coverage.
Please view CMS’ webpage for OTC tests to learn what providers are eligible to participate, additional information for billing the tests, and how to get paid. We’ve also provided a quick summary of how to bill below.
Use HCPCS code K1034 (COVID test self-admin/collect) to bill for a single test.
If you have no other diagnoses for the OTC COVID-19 tests, use suggested diagnosis code Z20.822: contact with and (suspected) exposure to COVID-19.
If you don’t have an attending physician for the OTC tests claim, enter: OTC
A billing provider NPI
“Self-referred” in the corresponding name field
Use the same NPI, Tax Identification Number (TIN) or PTAN that you use when you bill for flu, pneumococcal, or COVID-19 vaccines.
Use code 0300
Comprehensive outpatient rehabilitation facility providers: Use Code 0274
Federally qualified health centers and rural health centers:
Hospital-based: Bill tests through your hospital
Free standing or independent: Bill tests on a CMS-1500, as you would other normal laboratory services
Renal dialysis facilities: Bill tests with the AY modifier
Critical access hospitals and Indian health service facilities: Bill tests on a type of bill 014x
Opioid treatment program providers: Be sure each test is a separate line item with a unit of one, with a maximum of eight lines for each patient per claim per calendar month. Don’t add any other services (like demo code 99) to the claim.
CMS provided special guidance for Medicare Advantage plan patients. Submit the claims for Medicare Advantage plan enrollees to traditional Medicare using the Medicare Beneficiary Identifier (MBI) for processing and payment.