November 25, 2020
PARA
WeeklyeJOURNAL T hanksgiving E dition NEWS FOR HEALTHCARE DECISION MAKERS
Solving The Price Transparency Puzzle
Updat ed November 16, 2020 COVID-19 Gu ide
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Pre-Hospital Care Q&A
FAST LINKS
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Pre-Hospital Care Pr ice Tr an spar en cy Book let 10 Steps To Success Revised Hom e Healt h Pen alt y COVID-19 Coding Updated 1 M LNCon n ect s New slet t er
Days Left Until Deadline Administration: Pages 1-34 HIM /Coding Staff: Pages 1-34 Compliance: Page 3 COVID Guidance: Page 16
© PARA Healt h Car e An alyt ics an HFRI Company CPT® is a r egist er ed t r adem ar k of t h e Am er ican M edical Associat ion
PARA Weekly eJournal: November 25, 2020
COMMUNITY PARAMEDIC PROGRAM
Do you have any papers or documents regarding Community Paramedic Programs?
Answer: PARA hasn't published any papers on this topic, primarily because we have found no reimbursement available for community care paramedic programs. The closest match we could find is Medicare's ET3 program which is an innovative program that pays ambulance providers for treatment in place, without transport under certain conditions. Although the window to apply for participation in that model is currently closed, it will be interesting to see how it plays out. A link and an excerpt from the ET3 model Fact Sheet are provided here. https://innovation.cms.gov/files/fact-sheet/et3-eligibility-fs.pdf
A list of the approved applicants in North Carolina are provided below. It may be useful to reach out to the comparable organization for input on the application process and information about the success of the program after it's been in operation for a few months. The model begins on January 1, 2021. https://innovation.cms.gov/files/x/et3-selected-applicants.pdf
Additionally, you may want to sign up for the Medicare listserv providing email notices of updates. While the first round of applications for participation closed on 10/5/2020, additional rounds may be scheduled. To sign up for email updates, go to https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12521
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PARA Weekly eJournal: November 25, 2020
PRICE
TRANSPARENCY BOOKLET The Details. The Information. The Help.
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PARA Weekly eJournal: November 25, 2020
CM S began in t r odu cin g pr ice t r an spar en cy r equ ir em en t s in 2015 w h en it f ir st r equ ir ed h ospit als t o pr ovide a list of st an dar d ch ar ges u pon r equ est of t h e pat ien t . How ever , it w as n ot u n t il t h e 2019 f in al r u le t h at t h ey began t o r equ ir e h ospit als t o pu blish st an dar d ch ar ges in a f r equ en t ly u pdat ed, m ach in e-r eadable f or m at , on lin e, n ot ju st u pon r equ est . The President?s Executive Order in June 2019 promoted increased availability of meaningful pricing information for patients.Therefore, CMS? FY2020 Proposed Rule attempted to support this initiative by further defining the requirements for transparency. It requested payer-negotiated rates for charges and a separate list of ?shoppable? services including 230 hospital-selected and 70 CMS- selected services.The rule also outlined monitoring and enforcement including a monetary penalty and corrective action plans from hospitals. It is important to note that some states have been requiring a version of this rule for many years (except for the payer specific charges component).States?efforts to address surprise billing issues has not gone unnoticed.For example, some states have required annual posting of chargemasters, a selection of hospital financial reports, and/or a listing of common procedures for several years, demonstrating that states have been proactively addressing transparency for a while now. Other states are also beginning to require some form of price transparency in the coming year. As you can see in the timeline, The American Hospital Association (AHA) opposed the CMS proposed rule as it was written. Their belief is that this approach would only further confuse patients in their search for information and would disrupt contract negotiations between payers and hospitals. The current healthcare environment is riddled with various pressures in terms of thinning operating margins, health plan competition and a shortage of internal resources, namely IT Resources, to fulfill the requirements.Also, reimbursement methodologies and packaging rules disrupt our ability to provide a true ?list? of meaningful prices that would be actionable for patients. In June 2020, there was a summary judgement against the AHA where a Federal Judge upheld the legality of the rule stating that it would allow patients to make pricing comparisons between hospitals.The AHA is appealing this decision. 4
PARA Weekly eJournal: November 25, 2020
INTRODUCTION However, this may become a moot point because on June 30th, a group of Senators introduced the Healthcare PRICE Transparency Act written to demand transparency through legislation. The group of Republican Senators behind this legislation built on the president?s executive order as it would require hospitals and insurers to reveal cash prices and negotiated rates prior to the receipt of medical care.So, although we?ve been treating it as a CMS Requirement, chances are good that it could become a Federal Law, which eliminates any chance of challenging the requirements in court. Based on all of this, we are moving forward with implementing Price Transparency solutions effective January 1, 2021, for hospital clients and assisting in the data mining required to report this information to healthcare consumers.We, as an organization, have supported the idea of pricing transparency and true patient estimator tools for many years now.We are advocates of finding a solution that is capable of providing meaningful price information for patients and have worked to fulfill this need for many of our hospitals for many years. We believe that facilities must go the extra mile to ensure that the information they are providing to patients is useful and intuitive. While we don?t agree with some components of the rule and find issue with how some information is displayed, we realize ultimately, something of this nature will be implemented, so we are working with our clients to get them ahead of the curve.So, what does all of this mean, what are the requirements exactly, and what does this look like?The next few pages are a useful guide to CMS Price Transparency.
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PARA Weekly eJournal: November 25, 2020
THE CLOCK IS TICKING DATES, RULES & REGS The CMS final rule (CMS-1717-F2) aims to make hospital price information readily available to patients, so they can compare costs and make more informed healthcare decisions. Meeting the deadline and maintaining compliance will be no small endeavor for providers. Complying with the mandate will be a large undertaking that requires multi-disciplinary coordination. PARA HealthCare Analytics and HFRI can help navigate the dates, the rules and the regulations.
REQUIREMENT #1 By Jan u ar y 1, 2021, h ospit als ar e r equ ir ed t o be in com plian ce w it h t h e Hospit al Pr ice Tr an spar en cy r equ ir em en t s set f or t h in t h e CY 2020 Hospit al Ou t pat ien t PPS Policy Ch an ges (CM S-1717-FS).
REQUIREMENT #2 A com pr eh en sive m ach in e-r eadable f ile t h at in clu des t h e specif ic st an dar d ch ar ges f or all h ospit al it em s an d ser vices.
REQUIREMENT #3 A con su m er -f r ien dly display t h at in clu des t h e st an dar d ch ar ges f or at least 300 "sh oppable" ser vices t h at ar e gr ou ped w it h ch ar ges f or an cillar y ser vices t h at ar cu st om ar ily pr ovided by t h e h ospit al. 6
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PARA Weekly eJournal: November 25, 2020
SOLUTIONS FOR HOSPITALS THE
PARA Price Transparency Tool
In speaking with hospital associations, clients, and business vendor groups, we are finding that we are one of the only vendors who can completely satisfy, to the letter of the law, both CMS requirements in a fully customizable manner. Providers will need to publish both machine-readable format files and the patient facing price estimator is a value-add service for enhancing price transparency. PARA will use the CMS Extract file embedded in the Price Transparency Tool tab via the PARA Dat a Edit or to build the shoppable items/bundles. This can be done by the hospital, coupled with PARA?s guidance to ensure all primary procedures are linked to its customarily paired ancillary services. Turnaround time for the Pr ice Tr an spar en cy Tool is 60 days from submission of completed data, however subject to change as we get closer to the January 1, 2021 deadline. There is no limit at this time on how many clients PARA can assist with the CMS?2021 price transparency requirements as we are constantly monitoring workload and innovating our automation to support the data mining need for this initiative. 9
PARA Weekly eJournal: November 25, 2020
TAKE A TEST DRIVE DEMO THE PARA TOOL It's easy to find out just how the Price Transparency Tool from PARA Healt h Car e An alyt ics works. Click on the DEMO button to find out just how your patients can navigate through your installed Price Transparency Tool. They'll be impressed that your hospital has made comparing prices simple, accurate and informative. Try it out! You'll be impressed. But impressing you isn't our goal. Helping your hospital become compliant is our goal. Once you've taken the "test drive", contact one of our PARA Pr ice Tr an spar en cy experts to get started on your compliance journey.
PRESS HERE
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PARA Weekly eJournal: November 25, 2020
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PARA Weekly eJournal: November 25, 2020
PARA'S PRICE TRANSPARENCY TOOL
TENREASONS Why Hospitals Choose The Price Transparency Tool From PARA HealthCare Analytics and HFRI. 1.
Ensure compliance with the January 1, 2019 and January 1, 2021 CMS mandates for Price Transparency: a. Post a listing of all services and prices available at the facility in a machine-readable format b. Include payer specific reimbursement information for all services available at the facility
2.
Provide customized and meaningful information for patients. Take the guess work out of obtaining an estimate.
3.
Improve collections. Patients will know their liability before the service is provided. They can even prepay!
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Web based solution. Simple implementation. No software to install.
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Comprehensive tool that pulls a. Top services at a facility b. User?s insurance information via eligibility checking c. Registration information to return usage statistics readily available to the facility 12
PARA Weekly eJournal: November 25, 2020
PARA'S PRICE TRANSPARENCY TOOL
TENREASONS, cont. 6.
Highly customizable a. The style and functionality of the tool to be directly embedded on the facility website b. The services available on the Decision Tree and how they are presented (i.e. descriptions, categories) c. The Prices that are presented (e.g., Average Line Charge, Average Package Charge, Average CDM Charge, etc.) d. The programming to meet all expectations and functionality
7. 8. 9.
Always up to date with the latest information for all users. With no additional work on behalf of the hospital once implemented. Fully serviced and managed on PARA?s servers with all data and functionality accessible by the facility through the PARA Data Editor. Ongoing feature upgrades and improvements that reflect changes in practice, technology, and services. Reporting capabilities to review all activity on hospital website and what services are being shopped.
10. Most cost-effective solution in the industry. PARA?s
cost to deploy its solution is market competitive and in line with what CMS is saying healthcare organizations should pay for to implement a patient price estimator.
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PARA Weekly eJournal: November 25, 2020
10 STEPS TO SUCCESS 1. Take the Price Transparency test drive 2. Contact a PARA Accou n t Execu t ive to guide you through the process 3. Identify each hospital location that must make available its list of standard charges 4. Identify all items and services for which your hospital has established a standard charge 5. Gather the required data elements for each item and service 6. Select your file format 7. Name your machine-readable file according to the CMS naming convention 8. Post your machine-readable file prominently on a publicly available website 9. Update your comprehensive machine-readable file annually 10. Double check that you've met the requirements 14
PARA Weekly eJournal: November 25, 2020
LET OUR EXPERTS GUIDE YOU DON'T WAIT! CONTACT OUR EXPERTS
Violet -Archulet a-Chiu Senior Account Executive
Sandra LaPlace Account Executive
800.999.3332 X219
Randi Brant ner Vice President of Analytics 719.308.0883
varchuleta@para-hcfs.com 800.999.3332 X225 slaplace@para-hcfs.com
rbrantner@hfri.net
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
PARA Healt h Car e An alyt ics con t in u es t o u pdat e COVID-19 codin g an d billin g in f or m at ion based on f r equ en t ly ch an gin g gu idelin es r egu lat ion s f r om CM S an d payer s. All codin g m u st be su ppor t ed by m edical docu m en t at ion . Updat es f r om t h e pr eviou s ver sion of t h is COVID-19 paper ar e in dicat ed in r ed, an d t est t ables ar e u pdat ed. ICD-10-CM Of f icial Codin g an d Repor t in g Gu idelin es f or Cor on avir u s, ef f ect ive Apr il 1, 2020 t h r ou gh Sept em ber 30, 2020, m ay be dow n loaded f r om t h e lin k below : https://www.cms.gov/files/document/se20015.pdf
Coding for Confirmed Cases For confirmed cases of COVID-19, report ICD-10 CM code U07.1 (COVID-19).On Wednesday, March 18, 2020, the Centers for Disease Control (CDC) announced that the ICD-10-CM diagnosis code, previously slated to be effective October 1, 2020, will now be effective April 1, 2020. Report U07.1 for confirmed or presumptive positive COVID-19 cases.Presumptive positive tests are those that have shown positive at the state or local level; the Centers for Disease Control does not have to confirm the result.Except in cases of obstetric patients, sequence U07.1 first, followed by appropriate codes for associated manifestation(s). Patients who are admitted or present for a healthcare encounter because of confirmed COVID-19 during pregnancy, childbirth, or post-partum should be reported with a principal diagnosis of O98.5 (Other viral diseases complicating pregnancy, childbirth and the puerperium.) U07.1 should follow O98.5 then any appropriate codes for associated manifestation(s). 16
PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
- Pneumonia confirmed as due to the COVID-19 - assign codes U07.1 (COVID-19) and J12.89 (other viral pneumonia.) - Acute bronchitis confirmed as due to COVID-19, assign codes U07.1 (COVID-19) and J20.8 (acute bronchitis due to other specified organisms.) - Bronchitis Not Otherwise Specified (NOS) due to the COVID-19, assign codes U07.1 (COVID-19) and J40 (bronchitis, not specified as acute or chronic.) - Lower respiratory infection NOS confirmed as due to COVID-19, assign codes U07.1 (COVID-19) and J22 (unspecified acute lower respiratory infection.) - Respiratory infection NOS confirmed as due to COVID-19, assign codes U07.1 (COVID-19) and J98.8 (other specified respiratory disorders.) - Acute respiratory distress syndrome (ARDS), assign codes U07.1 (COVID-19) and J80 (acute respiratory distress syndrome.) Coding for Exposure to COVID-19 Report Z01.812 (Encounter for preprocedural laboratory examination) followed by Z20.828. Report Z03.818 (encounter for observation for suspected exposure to other biological agents ruled out) when there is a concern of possible exposure to COVID-19, but after evaluation of the patient was ruled out. Report Z20.828 (contact with and (suspected/possible) exposure to other viral communicable diseases) when there is actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19 and the test on the patient is either negative or unknown. Report any signs or symptoms associated with COVID-19 if present in the patient. Report P00.2 (Newborn affected by maternal infectious and parasitic diseases) when a newborn is born to a COVID-positive mother and the baby?s COVID-19 status is unknown. Screening for COVID-19 Prior to October 1, 2020, report Z11.59 (encounter for screening for other viral diseases) for COVID-19 screening of asymptomatic patients who have had no known virus exposure and the test results are either unknown or negative. Per the ICD-10-CM Official Guidelines for Coding and Reporting that became effective on October 1, 2020, during the Public Health Emergency, a screening code to test for COVID-19 is not appropriate. For encounters related to COVID-19 testing done as protocol for a procedure or admission ? asymptomatic patients should be coded with Z20.828(Contact with and (suspected) exposure to other viral communicable diseases). Source: : https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
Signs and symptoms without a definitive diagnosis of COVID-19 For patients presenting with signs or symptoms of COVID-19 but do not have a definitive diagnosis of COVID-19, report the appropriate code(s) for any associated manifestations.
COVID-19 Specimen Collection Hospital Outpatients: Effective March 1, 2020, HCPCS C9803 (hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2)(coronavirus disease [covid-19]), any specimen source)) may be reported by outpatient hospitals for collecting COVID-19 test swabs. On August 27, 2020, CMS clarified the correct use of modifier CS by providing a list of HCPCS codes that are appropriate for waiving cost-sharing for physicians, hospitals, and RHCs/FQHCs when providing medically necessary COVID-19 related Medicare Part B services. CMS waives beneficiary coinsurance and deductible amounts for these services when Modifier CS is appended. CMS will return claims containing modifier CS on procedure codes that are not listed.
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
CMS provides separate lists of CS-eligible HCPCS codes for three categories of medical providers. - Physicians/Non-physician Practitioners - Hospital OPPS Outpatient Departments - RHCs and FQHCs The document instructs Critical Access Hospitals to use the lists applicable to their billing method (Method I or Method II.) https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email -archive/2020-08-27-mlnc#_Toc49329805
The CMS spreadsheet is available in the Advisor tab of the PARA Data Editor, enter ?Cost? in the summary field for quick access:
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
CMS also revised its MLN on Medicare Fee-For-Service Response to the PHE on Coronavirus.The update can be found using the link below: https://www.cms.gov/files/document/se20011.pdf
Additionally, CMS continues to update the ?COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing? document posted on the CMS ?Current Emergencies? website. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf Free-standing physician practices may report evaluation and management code CPTÂŽ 99211 for COVID-19 swab collection for both new and established patients when no other E/M service is rendered. CMS states in its FAQ, that the physician/non-physician practitioner does not need to be present to report 99211 for the COVID-19 swab collection.
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
Free-standing physician practices may report evaluation and management code CPTÂŽ 99211 for COVID-19 swab collection for both new and established patients when no other E/M service is rendered. CMS states in its FAQ, that the physician/non-physician practitioner does not need to be present to report 99211 for the COVID-19 swab collection. Independent labs may report G2023 (specimen collection for severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source) andG2024(specimen collection for severe acute respiratory syndrome coronavirus?2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source). COVID-19 Testing Prior to Admission or Scheduled Procedure Hospitals paid under Inpatient Prospective Payment System (IPPS) must bill COVID-19 testing services performed before admission based on the 72-hour rule. When the test is performed three or fewer days prior to admission the payment for a COVID-19 test must be included on the inpatient claim.Critical Access Hospitals are not subject to this policy and will receive separate payment for COVID-19 testing performed in the outpatient department prior to the patient admission. CMS addresses pre-surgery COVID-19 testing in its Frequently Asked Questions on Medicare FFS Billing. If the services are part of the global surgical period, the COVID-19 test should be packaged with the surgery. https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf
For encounters related to COVID-19 testing done as protocol for a procedure or admission ? asymptomatic patients should be coded with Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases). Source: :https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
Inpatient COVID-19 On August 17, 2020, CMS revised its payment policy on inpatient admissions DRG payments.Beginning with admissions on or after September 1, 2020, only when a patient has been tested and found to be COVID-19 positive will the hospital receive the 20 percent increase in MS-DRG reimbursement. CMS states that tests performed within 14 days of admission may be manually documented in the patient?s record and that hospitals should code diagnoses in accordance with ICD-10-CM coding guidelines.CMS states they may conduct post-payment record reviews to verify documentation of the positive COVID-19 test.When not documented appropriately, the payment is subject to recoupment. https://www.cms.gov/files/document/se20015.pdf
CMS Allows Pro Fee for COVID-19 Isolation Counseling In a press release dated July 30, 2020, CMS announced that professionals may report an E/M code for the service of counseling patients who undergo COVID-19 testing to self-isolate after testing, even before results are available. https://www.cms.gov/newsroom/press-releases/cms-and-cdc-announce-provider-reimbursementavailable-counseling-patients-self-isolate-time-covid-19
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COVID-19 UPDATED 11/16/2020
According to the press release, ?Provider counseling to patients, at the time of their COVID-19 testing, will include the discussion of immediate need for isolation, even before results are available, the importance to inform their immediate household that they too should be tested for COVID-19, and the review of signs and symptoms and services available to them to aid in isolating at home. In addition, they will be counseled that if they test positive, to wear a mask at all times and they will be contacted by public health authorities and asked to provide information for contact tracing and to tell their immediate household and recent contacts in case it is appropriate for these individuals to be tested for the virus and to self-isolate as well.? Providers may claim reimbursement by reporting existing evaluation and management (E/M) codes.Enrolled providers may claim reimbursement for counseling to self-isolate no matter where a test is administered, including doctor?s offices, urgent care clinics, hospitals and community drive-thru or pharmacy testing sites. A counseling checklist, which could be helpful in guiding provider documentation of the counseling service, is provided: https://www.cms.gov/files/document/counseling-checklist.pdf
CMS offers an FAQ document for providers at the following link: https://www.cms.gov/files/document/covid-provider-counseling-qa.pdf
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COVID-19 UPDATED 11/16/2020
CMS also provides a Talking Points document to guide providers in having the conversation with patients about self-isolating. A link and an excerpt are provided: https://www.cms.gov/files/document/covid-provider-patient-counseling-talking-points.pdf
Special Services, Procedures and Reports CMS will accept new CPTÂŽ 99072 on professional fee claims with dates of service on or after September 8, 2020, although this code will not generate additional reimbursement. This code is not appropriate for facility fee billing. The MPFS Status indicator assigned to 99072 is B, ?Bundled code. Payment for covered services are always bundled into payment for other services not specified.? 99072- Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease Documentation requirements and reimbursement of 99072 may vary among payer plans. Many payers are following Medicare?s lead by bundling reimbursement for this supply code into the office visit.United Healthcare Medicare Advantage has posted the following announcement: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-reimbursement/ MEDADV-Supply-Policy.pdf
? ?For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPTÂŽ codes 99070 (supplies and materials, except spectacles, provided by the physician or other health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) and 99072 are not separately reimbursable in any setting.? 24
PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
COVID-19 Lab Tests Code selection depends on the payer and the test performed. Contact your local third-party payer directly to determine their specific reporting guidelines. For Medicare, report the code that matches the test source (CDC or non-CDC) or the technique.CMS offers guidance at the following link: https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf
?There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Healthcare providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001). A second new HCPCS code (U0002) 2019-nCoV Coronavirus, SARSCoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), nonCDC can also be used by laboratories and healthcare facilities. Both codes can be used to bill Medicare as well as by other health insurers that choose to utilize and accept the code. ?Additionally, on March 13, 2020, the American Medical Association (AMA) Current Procedural Terminology (CPT速) Editorial Panel has created CPT速 code 87635 (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). Laboratories can also use this CPT速 code to bill Medicare if your laboratory uses the method specified by CPT速 87635.?
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COVID-19 UPDATED 11/16/2020
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COVID-19 UPDATED 11/16/2020
*Medicare has not published national rates for these codes, but they may be priced by the local MAC. High throughput COVID-19 testing: A high-throughput machine requires specialized technical training. It can process more than 200 specimens a day.
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
Report U0003 in place of tests that were reported as 87635(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)when high-throughput technology is used. HCPCS U0004 should be reported in place of U0002(2019-ncov Coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc)when high-throughput technology is used. Until January 1, 2021, Medicare will pay $100 under the Clinical Lab Fee Schedule for high-throughput testing. The U0003 and U0004 codes should not be used when testing for COVID-19 antibodies.CMS provides a partial list of accepted technology high-throughput machines In Ruling 2020-1-R dated April 14, 2020: https://www.cms.gov/files/document/cms-2020-01-r.pdf Medicare re-evaluated testing resources in Ruling 2020-1-R2 dated January 1, 2021: https://www.cms.gov/files/document/cms-ruling-2020-1-r2.pdf Beginning January 1, 2021 and throughout the Public Health Emergency, Medicare FFS will pay $75 for COVID-19 tests performed using high throughput technology U0003 and U0004.However, Medicare will pay an additional $25 for new add-on HCPCS code U0005 to be reported if the COVID-19 lab test is completed within 2 calendar days of the specimen collection AND the laboratory completed 51% of high throughput testing for all patients (not only Medicare beneficiaries) in the previous month within two calendar days.
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COVID-19 UPDATED 11/16/2020
The laboratory must maintain records of its monthly assessments of timely results reporting.CMS instructs MACs to conduct claim reviews and audits to ensure providers are compliant with the Ruling. The U0005 add-on payment is for only Medicare FFS claims.It does not apply to Medicare Advantage plans. Medicare provides additional information on this requirement in several questions of the Frequently Asked Questions on Medicare FFS Billing on their website: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf
COVID-19 Antibody Testing Medicare instructs that 86328 is the most appropriate code to report for COVID-19 antibody testing performed in a single step (often a strip) with all critical components for the assay. COVID-19 antibody testing reported as 86769 may involve multi-steps where a diluted sample is incubated.
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
Medicare Monoclonal Antibody COVID-19 Infusion Program On November 9, 2020 the FDA issued an Emergency Use Authorization for the use of Bamlanivimab for investigative treatment of high risk COVID-19 positive patients exhibiting mild to moderate symptoms.In accordance with the CARES Act, Medicare will cover the infusions in healthcare settings, such as infusion centers and home health agencies, where providers are equipped and capable to treat a severe reaction (such as anaphylaxis) and can activate an EMS if warranted. The following HCPCS codes have been established for the monoclonal antibody and administration:
Final payment rates for the infusion and monoclonal product have not been established and are not active in Medicare?s payment systems.However, CMS states that Medicare will begin paying Q0239 injection $309.60, which will be geographically adjusted.The payment includes one hour of infusion followed by post-administration monitoring in an outpatient hospital setting.Medicare is expected to cover Bemlanivimab, when not provided free of cost, at reasonable costs in an outpatient hospital and may base physician office payments based on average wholesale price.Additional payment information will be published in a future CMS transmittal. Additional information is available through CMS: https://www.cms.gov/files/document/covid-medicare-monoclonal-antibody-infusion-program -instruction.pdf
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
Covid-19 Vaccine Codes In anticipation of approval from the FDA of a COVID-19 vaccine, the CDC offers a preview of information on the vaccines, although no CPTÂŽ/HCPCS have yet been assigned: https://www.cdc.gov/vaccines/programs/iis/code-sets.html?ACSTrackingID=USCDC_11_30 -DM42043&ACSTrackingLabel=New%20Preview%20of%20COVID-19%20vaccine%20codes %2011%2F4%2F2020&deliveryName=USCDC_11_30-DM42043
Modifiers and Condition Codes during the PHE Modifier CS: Effective March 18, 2020, under the under the Families First Coronavirus Response Act (FFCRA), Medicare will waive cost-sharing liability for certain evaluation and management services related to COVID-19 testing. The services must result either in an order or administration of COVID-19 testing or were provided to determine the need for a COVID-19 test. The evaluation and management may be provided either in person or through telehealth services. Append modifier CS to C9803 (hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2)(coronavirus disease [covid-19]), any specimen source) to ensure cost-sharing is waived, unless the testing is neither for suspected exposure or symptoms (e.g., presurgery testing, travel, and return to work testing.) Condition Code DR/Modifier CR: CMS has instructed providers to report these codes when care is provided under one of the Section 1135 waivers to address the Public Health Emergency. These codes do not affect payment. They are not necessary on Medicare telehealth services. When all services or items billed on the claim are related to a COVID-19 waiver, Condition Code DR is used by institutional providers and Modifier CR is for both institutional and non-institutional providers.On August 26, 2020, CMS revised its document that discusses the use of these modifiers and condition code DR in MLN SE20011 ?Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19).?
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
https://www.cms.gov/files/document/se20011.pdf
Commercial Insurers Coverage and billing requirements on COVID-19 vary based on the insurance plan.To avoid denials and payment delays, providers are encouraged to consult the plan involved prior to billing.The following website, compiled by AHIP, offers links to various insurance plan COVID-19 webpages: https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/
Uninsured COVID-19 Providers who have tested or provided services to uninsured (and in some cases undocumented) patients with a COVID-19 diagnosis after February 4, 2020 may enroll to file claims for reimbursement under the HHS COVID-19 Uninsured Program. The program covers qualified expenses for COVID-19 outpatient and inpatient services and will cover COVID-19 vaccinations when they become available.
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PARA Weekly eJournal: November 25, 2020
COVID-19 UPDATED 11/16/2020
https://www.hrsa.gov/coviduninsuredclaim
CMS COVID-19 Resources: Billing and coding guidance is available within the ?Frequently Asked Questions to Assist Medicare Providers? on the CMS ?Current Emergencies? website on the next page: https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/ Current-Emergencies-page
Coronavirus Waivers & Flexibilities: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current -emergencies/coronavirus-waivers
CMS Podcasts and Transcripts: https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts
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PARA Weekly eJournal: November 25, 2020
MLN CONNECTS PARA invites you to check out the mlnconnects page available from the Centers For Medicare and Medicaid (CMS). It's chock full of news and information, training opportunities, events and more! Each week PARA will bring you the latest news and links to available resources. Click each link for the PDF!
Th u r sday, Novem ber 19, 2020 New s -
CMS Releases Nursing Home COVID-19 Training Data with Urgent Call to Action Medicare FFS Estimated Improper Payments Decline by $15 Billion Since 2016 CMS Retiring Original Compare Tools on December 1 COVID-19: Health Care Operations Lessons and Fostering Professional Resilience Medicare Diabetes Prevention Program: Become a Medicare-Enrolled Supplier Recognizing Lung Cancer Awareness Month and the Great American Smokeout
Com plian ce - Hospice Care: Safeguards for Medicare Patients Even t s - CMS-CDC Fundamentals of COVID-19 Prevention for Nursing Home Management Call ? November 19 - Hospital Price Transparency Webcast ? December 8 M u lt im edia - Part A Cost Report Webcast: Audio Recording and Transcript View this edition as a PDF (PDF)
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