The rise of new and emerging infectious diseases poses a significant challenge for healthcare providers, not only in patient care but also in billing, coding, and reimbursement. Outbreaks like COVID-19, monkeypox, avian influenza, Ebola, and Zika virus demand rapid adaptations in ICD-10 and CPT coding, claim submissions, and insurance policies.
The complexity increases as government regulations evolve, requiring providers to stay ahead of coding updates to avoid claim denials and delayed reimbursements. Without accurate documentation and up-to-date codes, healthcare organizations risk financial losses and compliance issues.
How Emerging Infectious Diseases Impact Medical Billing?
The healthcare industry is no stranger to disruptions caused by new and emerging infectious diseases. However, these outbreaks bring more than just medical challenges—they also create significant billing and reimbursement hurdles.
Healthcare providers must quickly adapt to new diagnosis codes, billing guidelines, and reimbursement policies, all while ensuring compliance with regulatory agencies like the CDC, WHO, and CMS.
When a new infectious disease emerges, several factors contribute to billing complexities:
- Lack of pre-existing ICD-10 and CPT codes for the disease.
- Frequent policy changes by insurers that affect reimbursement rates.
- Increased claim denials due to coding errors or outdated guidelines.
- The rise of telehealth services, requiring separate coding and reimbursement structures.
Key Emerging Infectious Diseases and Their Billing Guidelines
1. COVID-19
COVID-19 fundamentally changed the way medical billing and reimbursement operate. The introduction of new testing, treatment, and vaccination procedures led to a rapid expansion of ICD-10 and CPT codes to accommodate different aspects of care.
ICD-10 Codes:
- U07.1 – COVID-19 (Confirmed diagnosis).
- Z20.828 – Contact with and suspected exposure to COVID-19.
- J12.82 – Pneumonia due to COVID-19.
CPT Codes:
- 87635 – COVID-19 PCR Test.
- 91300-91304 – COVID-19 vaccine administration.
Reimbursement Issues:
- Initial government-backed reimbursements (CARES Act) later shifted to private insurers.
- Claim rejections due to outdated coding or insufficient documentation.
- Challenges in billing for post-COVID complications (long COVID).
2. Monkeypox (Mpox)
After the 2022 monkeypox outbreak, healthcare providers had to quickly adjust billing practices for new testing and treatment procedures.
ICD-10 Code: B04 – Monkeypox.
CPT Codes: 87593 – Monkeypox virus PCR testing.
Billing Challenges:
- Delays in insurance approvals for vaccines and treatments.
- Emergency classification of monkeypox led to temporary reimbursement policies.
- Increased denials due to misclassification as a generic viral infection.
3. Avian Influenza (H5N1, H7N9, etc.)
Avian flu outbreaks are sporadic but high-risk, especially in cases of human transmission. Billing challenges arise due to specialized treatments and hospitalization requirements.
ICD-10 Code: J09.X1 – Influenza due to certain identified influenza viruses.
Reimbursement Issues:
- Limited insurance coverage for experimental antiviral treatments.
- Quarantine-related services may not be reimbursable under standard policies.
- Complications in billing for severe cases requiring ICU admission.
4. Ebola Virus Disease
Ebola’s high mortality rate and specialized care requirements make billing particularly complex. Healthcare facilities must ensure proper coding and documentation to receive reimbursement.
ICD-10 Code: A98.4 – Ebola virus disease.
Billing & Reimbursement Challenges:
- Expensive isolation and protective measures may not be fully reimbursed.
- Experimental treatments often fall outside standard insurance coverage.
- Government funding for outbreak responses may impact private insurer reimbursement.
5. Zika Virus
The 2016 Zika outbreak raised significant concerns regarding maternal and fetal care billing due to the virus’s impact on pregnancies.
ICD-10 Code: A92.5 – Zika virus disease.
Billing & Reimbursement Considerations:
- Congenital Zika syndrome-related claims often face delays.
- Long-term follow-up care for infants with microcephaly creates additional coding requirements.
- Public health funding covers some cases but varies by region.
Challenges in Medical Coding and Documentation
Billing for newly emerging diseases is a complex process due to rapid coding changes, delayed payer updates, and insufficient documentation. The most common challenges include:
Lack of Specific Codes for New Diseases: When a disease first emerges, providers must rely on generic codes until specific ones are created. This leads to claim denials and reimbursement delays.
Frequent Changes in Reimbursement Policies: Government agencies and insurers often update billing guidelines mid-pandemic, requiring constant adaptation by healthcare providers.
Increased Claim Denials Due to Coding Errors: Incorrect use of ICD-10 or CPT codes leads to higher claim rejection rates.
Telehealth Billing for Infectious Diseases: The rise of remote consultations during pandemics requires specific codes and reimbursement models, which often lag behind real-world needs.
Reimbursement Issues During a Public Health Crisis
Emerging infectious diseases create unprecedented challenges for reimbursement, often leading to delayed payments, claim denials, and policy changes that disrupt healthcare revenue cycles. During a public health crisis, providers must navigate complex reimbursement issues, including:
1. Changing Insurance Policies
- Insurance companies adjust their reimbursement criteria based on government mandates and emergency declarations.
- Policies for testing, treatment, and hospitalization reimbursement can change mid-pandemic, making it difficult for providers to keep up.
- Example: COVID-19 testing was initially covered by federal programs, but later shifted to private insurance and patient responsibility.
2. Increased Claim Denials and Audits
- Incorrect or outdated codes result in higher claim rejection rates.
- Government programs and insurers tighten auditing practices, leading to more scrutiny on claims related to new diseases.
- Example: COVID-19 long-haul syndrome claims were frequently denied due to unclear diagnostic criteria and lack of established coding.
3. Telehealth Billing Complexities
- Telemedicine use surged during outbreaks, requiring new billing codes and reimbursement structures.
- Insurers often limit telehealth reimbursements, leading to financial challenges for providers.
- Example: CMS created temporary telehealth codes for COVID-19, but reimbursement varied across states and payers.
How Healthcare Providers Can Adapt to New Billing Challenges?
To minimize revenue loss and ensure timely reimbursement, healthcare providers must adopt proactive billing strategies:
- Regularly monitor CMS, WHO, and CDC updates for new coding guidelines.
- Subscribe to payer bulletins and industry newsletters to track policy adjustments.
- Automation tools can help detect coding errors, optimize claims submissions, and prevent denials.
- AI-based billing software ensures real-time compliance with changing regulations.
- Hiring or outsourcing certified medical coders reduces errors and improves claim approval rates.
- Medical billing experts stay up-to-date with payer policy changes and can expedite appeals for denied claims.
The Role of Government and Regulatory Bodies in Disease-Related Billing
Regulatory agencies play a crucial role in adapting billing and reimbursement policies for emerging diseases. Healthcare providers must understand how these bodies influence medical billing:
1. CMS (Centers for Medicare & Medicaid Services)
- Issues temporary and permanent billing codes for new diseases.
- Provides emergency reimbursement adjustments for outbreak-related care.
- Example: CMS expanded telehealth billing codes during COVID-19.
2. WHO (World Health Organization)
- Develops and updates ICD-10 codes for new diseases.
- Issues global healthcare billing and classification guidelines.
3. CDC (Centers for Disease Control and Prevention)
- Provides clinical coding guidance for disease diagnosis and treatment.
- Releases testing and vaccination billing recommendations.
Conclusion
The impact of emerging infectious diseases on medical billing is profound, requiring constant adaptation to new codes, insurance policies, and reimbursement structures. As diseases like COVID-19, monkeypox, avian influenza, Ebola, and Zika virus continue to emerge, healthcare providers must navigate coding complexities, claim denials, and policy shifts to ensure proper reimbursement.
For a comprehensive solution to infectious disease billing challenges, visit MedXpert Services – Infectious Disease Billing Services to explore how expert billing support can help your practice streamline processes and maximize reimbursements.
