By Kristine Tomzik, Jan Elezian, & Michael Kotch
As of May 11, 2020
The outbreak of COVID-19 has brought many healthcare providers, including testing labs and healthcare practitioners with new sets of reporting codes to seek reimbursement for related services. Each time a payer (regardless of whether Medicare, Medicaid, or a private insurer) renders payment there is a risk the service will be audited for documentation in the medical record supporting the medical necessity of the test or service.As with all codes there is education, template development and documentation required.Documentation guidelines in electronic health records (EHRs) should be checked to be sure services are documented accurately.Updated Clinical Documentation Improvement (CDI) query templates are also a key resource to practitioners.Lack of documented medical necessity will take the form of paybacks and possibly, without support for the services, the accusation of fraud.
Please make sure to consult the latest guidance before applying these rules, see the associated links at the end of this Post.
Let’s begin with outpatient codes, specifically the COVID-19 lab test. The new diagnosis code, U07.1 is applied once the test is complete and the presence of COVID-19 is confirmed. Presumptive positive test results should be coded as confirmed (U07.1). If the case is documented as “suspected”, “possible”, “probable”, or “inconclusive” for COVID-19, do not assign code U07.1. For a patient showing symptoms, such as unspecified fever (R50.9), shortness of breath (R06.02), and/or cough (R05), a diagnosis code of a symptom relating to COVID-19 supports the claim. Code Z20.828 may be used when the patient is tested due to contact with and suspected exposure to a viral communicable disease (COVID-19). If a suspected exposure is ruled out, assign code Z03.818.
The lab test itself is coded as U0001 which includes documented and billed tests performed specifically at CDC laboratories. U0002 includes documented and billed tests performed at clinical laboratories outside of CDC. Medicare started accepting these codes on 4/1/2020. The codes will be retroactive to account for testing done on or after 2/4/2020.
Medicare will reimburse providers about $35 for claims coded with U0001 and approximately $51 for claims with U0002, however, other payers may pay these claims at usual and customary or contracted rates.
Additional lab test codes include:
87635 (Novel coronavirus testing through infectious agent detection by nucleic acid)
86328 (Antibody testing using a single step method immunoassay)
86769 (Antibody testing using a multiple step method)
Relaxed Billing Requirements:
CMS announced on 4/30/2020 that under relaxed rules, Medicare will pay for laboratory tests required for a COVID-19 diagnosis without a written order from the treating physician or other practitioner. If an order is not written it is not required that the ordering physician/practitioner’s National Provider Identifier (NPI), is on the claim. If an order is written, include the NPI on the claim, consistent with current billing guidelines.
As of May 1, 2020:
HCPCS codes U0002 and 87635 must be reported with modifier QW to be recognized as a test that can be performed in a facility having a current Clinical Laboratory Improvements (CLIA) certificate of waiver. Medicare will permit the use of codes U0002QW and 87635QW for claims submitted by facilities with a valid, current CLIA certificate of waiver with dates of service on or after March 20, 2020.
For most patients, the Medicare 1135 waiver states that cost sharing does not apply for testing related services between 3/18/2020 and until the end of the pandemic being declared. When billing Part B Medicare claims use the -CS modifier to note that the service is subject to the cost sharing waiver. Medicare patients should not be charged any co-insurance or deductible amounts. Avoid double payments by auditing to ensure that patients are not charged co-pays or deductibles as Medicare will reimburse at 100% for the payment when the -CS modifier is applied. Seek advice from other payers as to whether they have a modifier requirement.
Specimen Collection Services
The reimbursement for specimen collection for COVID-19 testing is identified by HCPCS codes for dates of service on or after 3/1/2020 and billable by independent clinical diagnostic labs. These include the following:
G2023 – Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), coronavirus (COVID-19, any specimen source and;
G2024 – Specimen from an individual in a skilled nursing facility or by a lab on behalf of a Home Health agency, any specimen source.
As of May 1, 2020:
99211 – Low level office or other outpatient visit. Physicians and NPP’s may use CPT code 99211 to bill for services furnished incident to their professional services, for both new and established patients, when assessing symptoms and collecting specimens for COVID-19 testing.
C9803 - Hospital outpatient clinic visits specimen collection for severe acute respiratory syndrome [COVID-19], any specimen source, is now effective for services provided on or after March 1, 2020. Outpatient Medicare claims received after May 1, 2020, with HCPCS codes G2023 or G2024 will be returned with edit W7062. These claims can be re-submitted as a packaged service to include HCPCS code C9803, when appropriate.
CMS is waiving all cost sharing on these codes when all requirements under section 6002(a) of the Families First Coronavirus Response Act are met.
Due to regulatory flexibilities based on the President’s emergency declaration CMS had broadened access to Medicare telehealth services. Medicare can pay for office, hospital, and other visits furnished by telehealth across the country and including the patient’s home starting March 6, 2020. Providers such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers are included. CMS is also providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth services paid by a federal healthcare program. Audit to ensure that cost sharing is reduced or waived consistently. The specific set of services that may be provided include:
E/M (common office visits),
Mental health counseling, and
Preventive health screenings.
Although telehealth services require that a patient have a prior established relationship with a provider, HHS may waive this requirement during the COVID-19 public health emergency 1135 waiver period.
For telehealth services, use the place of service code that would normally be used if that service was delivered in person. These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits. Attach modifier -95 to the claims to note that the service was provided by telehealth.
If the circumstance is such that the patient and provider are in the same location (for instance, in different areas of the same hospital building), this is not considered to be a telehealth service. Instead, report the service as an in-person service (without modifier 95).
CMS has temporarily added to their list of acceptable telehealth codes to include telehealth services rendered by emergency department (ED) physicians. The following evaluation and management codes (E/M) are added to the list for the duration of the COVID-19 national emergency:
ED level CPT codes 99281 – 99285
Critical care codes 99291 and 99292
Observation codes 99217-99220, 99224-99226, and 99234-99236
Additional CMS changes announced on April 30, 2020 are as follows:
CMS is waiving limitations on the types of care providers eligible for Medicare reimbursement. Physical and occupational therapists and speech language pathologists are now allowed to offer and bill for telehealth services.
Hospitals can now bill for outpatient services furnished remotely by hospital-based practitioners, including telehealth to patients at home – considered a “temporary provider-based department of the hospital.”
CMS is expanding the list of audio-only phone services reimbursable through Medicare to include many behavioral health and patient education services. And, the agency will increase reimbursements for those services to match similar office or outpatient services, retroactive to March 1, 2020.
The agency is speeding up the process by which it adds new services to the list of telehealth services reimbursable under Medicare.
Federally qualified health clinics (FQHCs) and rural health clinics (RHCs) will now be reimbursed for providing telehealth services. RHC and FQHC physicians must use HCPCS code G2025 for distant site telehealth services to identify services that were furnished via telehealth beginning on January 27, 2020. Medicare’s payment to RHCs and FQHCs for distant telehealth services is set at $92.03.
CMS is waiving the video requirement for certain evaluation and management services, enabling providers to bill Medicare for services delivered by audio-only phones.
Note that CMS has not approved reimbursement for telehealth services related to home health and hospice.
These complex rules are being added/modified/revised daily. Diligence in communication, monitoring, and auditing is needed to reduce errors that will cause future paybacks and possibly other determinations.
References and Sources
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