The CPT Editorial Panel at the AMA has created and approved new COVID-19 vaccine and administration codes for Moderna, Pfizer, and Novavax manufacturers. CMS has the complete list of vaccine information here.

• 4 new CPT codes have been published to describe the Moderna pediatric vaccine and vaccine administration for ages 6 months through 5 years, effective as of June 17, 2022:
  • 91311: SARSCOV2 VAC 25MCG/0.25ML IM (Vaccine)
  • 0111A: ADM SARSCOV2 25MCG/0.25ML1ST (First Dose)
  • 0112A: ADM SARSCOV2 25MCG/0.25ML2ND (Second Dose)
  • 0113A: ADM SARSCOV2 25MCG/0.25ML3RD (Third Dose)
• 3 new administrative CPT codes have been published to describe the existing Moderna vaccine CPT code 91309 for ages 6 years through 11 years, effective as of June 17, 2022:
  • 0091A: ADM SARSCOV2 50 MCG/.5 ML1ST (First Dose)
  • 0092A: ADM SARSCOV2 50 MCG/.5 ML2ND (Second Dose)
  • 0093A: ADM SARSCOV2 50 MCG/.5 ML3RD (Third Dose)
• 4 new CPT codes have been published to describe the Pfizer pediatric vaccine and vaccine administration for ages 6 months through 4 years, effective as of June 17, 2022:
  • 91308: SARSCOV2 VAC 3MCG TRS-SUCR (Vaccine)
  • 0081A: ADM SARSCOV2 3MCG TRS-SUCR 1 (First Dose)
  • 0082A: ADM SARSCOV2 3MCG TRS-SUCR 2 (Second Dose)
  • 0083A: ADM SARSCOV2 3MCG TRS-SUCR 3 (Third Dose)
• 3 new CPT codes have been added for the Novavax adult vaccine and administration for 18 years and older, effective as of July 13, 2022.
  • 91304: SARSCOV2 VAC 5MCG/0.5ML IM (Vaccine)
  • 0041A: ADM SARSCOV2 5MCG/0.5ML 1ST (First Dose)
  • 0042A: ADM SARSCOV2 5MCG/0.5ML 2ND (Second Dose)

The CPT Editorial Panel at the AMA has created and approved new COVID-19 vaccine and administration codes for Pfizer, Moderna and Janssen manufacturers. See the AMA CPT Category Descriptors here.

• 3 new CPT codes have been published to describe the Pfizer Pediatric vaccine and vaccine administration codes for ages 5 to 11 and are effective as of October 29, 2021:
  • 91307: SARSCOV2 VAC 10 MCG TRS-SUCR   (Vaccine)
  • 0071A: ADM SARSCV2 10MCG TRS-SUCR 1 (First Dose)
  • 0072A: ADM SARSCV2 10MCG TRS-SUCR 2 (Second Dose)
    
    
• 2 new CPT codes have been added for the low dose Moderna Adult Vaccine and Administration code, effective October 20, 2021.
  • 91306: SARSCOV2 VAC 50MCG/0.25ML IM (Vaccine)
  • 0064A: ADM SARSCOV2 50MCG/0.25MLBST (Booster)
  • 0034A: ADM SARSCOV2 VAC AD26 .5ML B (Booster)
    

• 1 new CPT code has been added for the booster dose of the Janssen (91303) for adults published on October 27, 2021 and effective October 20, 2021:
  • 0034A: ADM SARSCOV2 VAC AD26 .5ML B (Booster)

The CPT Editorial Panel at the AMA has created and approved two new COVID-19 administration codes for the 3^rd doses of Pfizer and Moderna. See the AMA CPT Category Descriptors here.

• 2 new CPT codes have been published to describe the vaccine administration codes and are effective as of August 12, 2021:
  • 0003A: ADM SARSCOV2 30MCG/0.3ML 3^rd Dose: Pfizer
  • 0013A: ADM SARSCOV2 100MCG/0.5ML 3^rd Dose: Moderna

In anticipation of the expected FDA approval, the AMA has created COVID-19 vaccine and administration codes for Janssen (Johnson & Johnson). See the CPT Assistant Coding Guide here. The FDA has announced that approval for this single-dose vaccine will likely come in late February 2021. Two new CPT codes have been published to describe the vaccine and administration codes:

91303 (Janssen vaccine code) with admin code 0031A

The AMA has also created COVID-19 vaccine and administration codes for AstraZeneca-Oxford. See the CPT Assistant Coding Guide here. The FDA has delayed the approval of this vaccine for now but has stated that approval may happen in April 2021. Three new CPT codes have been published to describe the vaccine and administration codes:

91302 (AstraZeneca vaccine code) with admin codes 0021A (1st dose) and 0022A (2nd dose)

See crosswalk below for additional details:

The above codes are not effective until the FDA approves the emergency authorization. Once approved, CMS will release the codes in the next quarterly codeset update. 

See updates on:

• COVID-19 Vaccine Coding and Billing
• Expansion of Telehealth Services
• Strategies for Pandemic Hospitalization Surge

COVID-19 Vaccine Coding and Billing

The CPT Editorial Panel has approved the first set of COVID-19 vaccine and administration codes. See the CPT Assistant Coding Guide here.

• 6 new CPT codes have been published to describe the vaccines by Pfizer and Moderna.
  • 91300 (Pfizer vaccine code) with admin codes: 0001A (1st dose), 0002A (2nd dose).
  • 91301 (Moderna vaccine code) with admin codes 0011A (1st dose), 0012A (2nd dose).
  • See crosswalk below for additional details:
  

Expansion of Telehealth Services

CMS Announces the Permanent Expansion of Medicare Telehealth Services and Improved Provider Payments. See the CMS newsroom announcement here.

Highlights include:

• Expansion of Telehealth services and improving Rural Health
• Payment for office and outpatient E&M and comparable visits
• Flexibilities to allow non-physician practitioners to provide care

Strategies for Pandemic Hospitalization Surge

CMS Announces a Comprehensive Strategy for COVID-19 Surge with Hospitals. See the CMS newsroom announcement here.

Highlights include:

• Acute hospital care at home
  • Streamlined waiver request process. Access the portal here.
• Flexibilities for Ambulatory Surgical Centers. Access additional details here.

• Emergency Use Authorization for COVID-19 Antibody Therapy
  • Effective November 9, 2020, Medicare beneficiaries can receive the monoclonal antibody therapy (Bamlanivimab) to treat mild to moderate cases of COVID-19 with no cost-sharing. The FDA has approved emergency use authorization for this infusion therapy. See the authorized use fact sheet here.
    • Eligible patients must be 12 years of age or older and weigh at least 40 kg and be at a higher risk for progressing to severe COVID-19.
    • CMS has identified two specific product and administration codes for billing and payment:
      • Q0239: Injection, bamlanivimab, 700 mg
      • M0239: Intravenous infusion, bamlanivimab
      • Click here to view the program instructions for billing and payment
        
• CMS Releases Payment Changes for COVID-19 Testing in 2021
  • In April of 2020, CMS created new, high-throughput lab testing codes (U0003 and U0004) to support faster COVID-19 diagnostic testing.
  • For Lab tests performed with the appropriate technology, the reimbursement rate was $100.00.
  • CMS announced a change to this policy effective January 1, 2021.
    • This ruling creates an add-on payment code (U0005) for lab tests performed using high throughput technology (U0003 and U0004) that are completed within two calendar days of the date/time of specimen collection.
    • Payment for U0005 will be $25, and payment for U0003 or U0004 will be $75.
    • The objective is to create a financial incentive for the service provider to complete testing in 2 calendar days to receive the $25 payment.
    • The breakdown of payment changes includes:

• • • • Visit the CMS billing FAQ document here
• CMS Expands Medicare Telehealth Services
  • 11 CPT codes have been added to the Medicare Telehealth services list, effective immediately.
  • Medicare will pay eligible practitioners that provide these services through the duration of the public health emergency (PHE).
  • The new Telehealth services include cardiac and pulmonary rehab and analysis and programming for some neurostimulator services.
  • Below is the list of added codes:
    

• CMS Announces the Fourth COVID-19 (IFC-4) Interim Final Rule with Comment Period
  • CMS removes administrative barriers for patient access to COVID-19 Vaccines (when available).
  • State flexibility for Medicaid enrollment during the PHE.
  • Enhanced Medicare payments for COVID-19 treatments.
  • Price transparency for COVID-19 testing.
  • Click here for access to the IFC-4 fact sheet.

Two new CPT Category I Codes have been approved by the CPT Editorial Panel for expedited publication. The AMA has published an updated guide with additional information dated September 8, 2020. Highlights include:

• Effective September 8, 2020: To be published in the CPT 2022 Manual
  • 86413: SEV AQT RESPIR SYND CORONAVIRUS 2 ANTIBODY QUAN
    • New SARS-CoV-2 testing code for reporting quantitative antibody detection.
    • This code is meant to measure antibodies and assist with investigating immune response in patients tested.
    • The goal of this new assay is to assist researchers in understanding the epidemiology, pathology, prevention, and treatment of COVID-19.
  • 99072: ADDL SUPL MATRL&STAF TM DRG PHE RES-TR NFCT DS
    • This code has been created to capture additional supplies and clinical staff time required to alleviate the virus transmission over and above typical usage while providing treatment to patients. This is in effect during a Public Health Emergency only.
    • The code is only to be reported once per in-person patient encounter.
    • Payment information has not been released at this time.
    • Payer processing systems may or may not recognize this code and you should monitor to determine appropriate reimbursement.
• For additional coding guidance, please refer to the CPT Assistant September Special Addition here.

• QW Modifier Now Required for Procedure Code 87426
  • CMS has announced that HCPCs code 87426 should be submitted with the QW modifier.
    • More information can be found here.
    • The effective date of this change has been the subject of debate, but various professional coding advisors have agreed that the QW modifier should be added effective immediately to 87426 for any date of service on or after June 25, 2020.

• New Laboratory Codes Announced
  • COVID-19 Testing: Recent additions to Category I Pathology and Laboratory and Proprietary Laboratory Analysis Codes have been published by the AMA in an updated guide on August 10, 2020. Highlights include:
    • Effective August 10, 2020: To be published in the CPT 2022 Manual
      • 86408: Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]); screen
      • 86409: Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]); titer
      • 0225U: Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets
      • 0226U: Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), ELISA, plasma, serum
    • Effective June 25, 2020: To be published in the CPT 2022 Manual
      • 87426: Infectious agent antigen detection by immunoassay technique
      • 0223U: Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets
      • 0224U: Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed

• HHS has extended the Medicaid and CHIP Provider Relief Fund distribution application deadline to August 28^th, 2020.
• President Trump has signed an executive order to expand Telehealth benefits permanently to Medicare beneficiaries beyond the Public Health Emergency.
• CMS released their proposed 2021 physician fee schedule.
  • The comment period is open until October 5^th, 2020. Those interested can submit comments here. 
  • Physician Fee Schedule highlights include:
    • Proposed adoption of revised and increased work RVUs for Evaluation and Management services.
    • CPT code changes for codes 99202—99215, and a proposed increase in payments for those services.
    • Add-on HCPCS codes for Evaluation and Management services related to visit complexity.
    • Addition of two new HCPCS codes, G2064 and G2065, to the general care management HCPCS code, G0511, for Rural Health Clinics and FQHCs.
    • Due to the pandemic, CMS had reduced the number of proposed changes to the Quality Payment Program in 2021 including delayed timelines for MIPS and MVPs.
    • Proposed updates for work and/or practice expense (PE) values for certain procedure codes.
    • New telehealth services covered under Medicare will expand the use of telehealth technologies among Medicare beneficiaries. Main items include:
      • Direct Supervision for providers via Telehealth and Incident-To Billing
      • Removal of Frequency Limitations for Nursing Facility and Hospital Inpatient Services
      • Additional Guidance for Communications Technology Based Services (CTBS)
      • New Telehealth Services For 2021
        • CMS has proposed adding nine new codes to the approved Telehealth Services list, which include:

Deadlines have been extended for several COVID-19 related programs. CMS is also continuously updating their FAQ document for providers.

• The Public Health Emergency (PHE) has been extended 90 days beyond the previous July 25^th deadline.
• HHS has extended the Medicaid and CHIP Provider Relief Fund distribution provider application deadline to August 28^th.
• Paycheck Protection Program (PPP) deadline has been extended. The application period was set to expire on June 30^th, but businesses will now have until August 8^th to apply. 

CMS has announced flexibilities for several Innovation Center Models. Please see highlights listed below and refer to the comprehensive chart for greater details.

Financial Methodology Changes

• Bundled Payments for Care Improvement Advanced Model: CMMI is allowing the option for participants to exclude clinical episodes from reconciliation for 2020. Also, if participants decide to retain risk, certain clinical episodes with a COVID-19 diagnosis may be excluded.
• Comprehensive Care for Joint Replacement Model: Participants may remove downside risk by capping episode payments. Also, the appeals timeline has been changed from 45 days to 120 days for years 3 and 4.
• Oncology Care Model: Participants can decide to forgo upside/downside risk for periods impacted by the COVID-19 PHE.
• Medicare ACO Track 1+ Model: Treatment of COVID-19 episodes of care will be removed applying to the Medicare Shared Savings Program Extreme and Uncontrollable Circumstances policy. This will apply to 2020 financial reconciliation.

Quality Reporting Changes

• Oncology Care Model: Some reporting requirements are now optional including aggregate-level and beneficiary-level reporting. Cost and resource utilization reporting has also been removed for July/August 2020.
• Medicare ACO Track 1+ Model: The Medicare Shared Savings Program Extreme and Uncontrollable Circumstances policy will be applied for participants reporting in 2019 and 2020.
• Home Health Value-Based Purchasing Model: CMMI has aligned submission requirements with extensions and will grant some exceptions to data reporting during the PHE.

Model Timeline Changes

• Comprehensive Care for Joint Replacement Model: Performance year 5 will be extended through March 2021.
• Direct Contracting (Global and Professional) Model: Cohort #1 will be delayed until April 1, 2021. An application cycle will be created during 2021 to launch for a second cohort January 1, 2022.
• Oncology Care Model: The timeline has been extended through June 2022 allowing for an additional year.
• Medicare ACO Track 1+ Model: Agreements may be extended on a voluntary basis for one year through December 2021.

Please note we made a correction to our 5/1/20  post on 5/4/20:

• We incorrectly referenced the Place of Service code that should be used in billing for 99441-99443.
• This was corrected to reflect the accurate approach—CMS recommends using the POS where the service would typically have been performed.
• Please see the updated communication for additional details.

See updates on:

• Claim Refinements for RHCs for Telehealth Services
• Claim Refinements for FQHCs for Telehealth Services
• Claim Refinements for Telephone Only Services
• Newly Updated CMS FAQs for Fee-For-Service Billing During COVID-19 PHE

CMS has been providing incremental and evolving updates on their new policies for FQHC/RHC telehealth services and the billing implications of these changes. Below are CMS’s most recent updates.

Claim Refinements for RHCs for Telehealth Services

• For telehealth services furnished between January 27, 2020, and June 30, 2020
  • RHCs must report HCPCS code G2025 on their claims with the CG modifier.
  • Modifier “95” may also be appended but is not required.
  • These claims will be paid at the RHC’s all-inclusive rate (AIR), plus they will automatically be reprocessed beginning on July 1, 2020, at the $92.03 rate.
  • RHCs do not need to resubmit these claims for the payment adjustment.
  • Beginning July 1, 2020, RHCs should no longer put the CG modifier on claims with HCPCS code G2025.

RHC Claims for Telehealth Services from January 27, 2020 through June 30, 2020

RHC Claims for Telehealth Services Starting July 1, 2020

Claim Refinements for FQHCs for Telehealth Services

• For telehealth services furnished between January 27, 2020, and June 30, 2020, that are also FQHC qualifying visits
  • FQHCs must report three HCPCS/CPT codes for distant site telehealth services:
    • The FQHC Prospective Payment System (PPS) specific payment code (GO466, G0467, G0468, G0469, or G0470)
    • The HCPCS/CPT code that describes the services furnished via telehealth with modifier 95
    • And G2025 with modifier 95
  • These claims will be paid at the FQHC PPS rate until June 30, 2020, and will be automatically reprocessed beginning on July 1, 2020, at the $92.03 rate.
  • FQHCs do not need to resubmit these claims for the payment adjustment.
• When furnishing services via telehealth that are not FQHC qualifying visits
  • FQHCs should hold these claims until July 1, 2020, and then bill them with HCPCS code G2025.
  • Modifier 95 may be appended but it is not required.
• Beginning July 1, 2020, FQHCs will only be required to submit G2025.
  • Modifier 95 may be appended but it is not required.

Example of FQHC Claims for Telehealth Services January 27, 2020 through June 30, 2020

FQHC Claims for Telehealth Services Starting July 1, 2020

Claim Refinements for Telephone Only Services

• Announced in a CMS update released on April 30: Effective March 1, 2020, the approved list of telehealth services now includes CPT codes 99441, 99442, and 99443.
• These are defined as audio-only telephone evaluation and management (E/M) services.
• RHCs and FQHCs may furnish these services and should bill for these services using the newly established G code, G2025.
• RHCs and FQHCs must meet all requirements for these services in order to bill. Meaning:
  • Applies to physicians or qualified health care professionals who may report E/M services.
  • Must provide at least five (5) minutes of telephone E/M services to an established patient, parent, or guardian.
  • Services may not be billed if they are related to a previous E/M service provided within the past 7 days, and may not lead to an E/M service or procedure within the next 24 hours.
• Several state Medicaid agencies are also allowing audio-only services to qualify as telehealth services and to be billed as telehealth services.
• The patient chart must note that the patient does not have video capabilities and therefore the encounter took place via a telephone only connection.

Newly Updated CMS FAQs for Fee-For-Service Billing During COVID-19 PHE

• CMS has been publishing an FAQ document for issues related to Fee-for-Service billing for Lab, Telehealth, and other COVID-19 related changes.
• CMS updated this document on May 1, 2020 and it is quite comprehensive.
• We encourage groups to review this if they have policy questions.

See additional information from CMS.

See updates on:

• Further Expansion of Telehealth
• CMS Further Expands COVID-19 Diagnostic Testing
• Flexibility in Hospitals Relocating Provider-Based Outpatient Facilities
• Financial Protection for ACOs

Further Expansion of Telehealth

• Types of practitioners
  • CMS is waiving limitations on the types of clinical practitioners that can furnish telehealth services.
  • Prior to this change, only doctors, nurse practitioners, physician assistants, and certain others could deliver telehealth services.
  • Practitioners including physical therapists, occupational therapists, and speech language pathologists can now bill for telehealth services.
• Phone calls now treated similar to telehealth visits
  • CMS is waiving the video requirement for certain telephone evaluation and management services and adding them to the list of Medicare telehealth services.
  • CMS previously announced that Medicare would pay for certain audio-only telephone services, but at lower rates than audio and video services (telehealth).
  • CMS is now increasing payments for these telephone visits to match payment levels for similar office visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.
    • Specifically, CMS is instructing groups to continue to bill for phone calls using codes 99441 to 99443, however they will be paid at the same rate as a comparable E&M level service.
    • New! Updated 5/4/20: Use the place of service that would have been furnished (likely POS 11) and since these services are now considered telehealth services, add modifier 95.
  • Consistency of "time" guidelines for telehealth and office visits
    • Confusingly, CMS had previously announced different guidelines related to the time spent with patients relative to the visit levels for telehealth.
    • CMS has changed its position and is requesting groups use the same guidelines for determining the visit levels for telehealth as traditional office-based E&M services.

CMS Further Expands COVID-19 Diagnostic Testing

• CMS removes requirement of providers ordering tests
  • CMS continues to support efforts to have as many people tested as possible.
  • CMS will no longer require a treating physician or other practitioner to “order” tests for reimbursement purposes.
  • During the PHE, CMS will pay for tests when ordered by any healthcare professional authorized to do so under state law.
  • With these changes, beneficiaries can get tested at “parking lot” test sites operated by pharmacies and other entities consistent with state requirements.
• CMS expands payments for specimen collection
  • CMS previously announced actions to pay laboratories for technicians to collect samples for COVID-19 testing from homebound beneficiaries and those in certain non-hospital settings.
  • CMS will now pay physicians and NPP’s for specimen collection (furnished incident to their professional services) using CPT code 99211 for both new and established patients.
  • Cost-sharing for this specimen collection is waived and services should be billed using the CS modifier.
• CMS to pay for antibody testing
  • To help facilitate expanded testing and reopen the country, CMS is covering serology (antibody) tests to help determine if a person has developed an immune response to COVID-19.
  • Medicare and Medicaid will also cover laboratory processing of FDA-authorized tests that beneficiaries self-collect at home.

Flexibility in Hospitals Relocating Provider-Based Outpatient Facilities

• Historically, CMS paid certain provider-based hospital departments (PBDs) at the lower Physician Fee Schedule rates, rather than the Outpatient Prospective Payment System (OPPS) rates.
• During the PHE, CMS will allow PBDs that relocate off-campus to obtain a temporary exception and continue to be paid under the higher OPPS rate schedule.

Financial Protection for ACOs

• CMS is making changes to help provide the 517 ACOs with greater financial stability and predictability during the COVID-19 pandemic.
• CMS considers ACOs as being impacted by “extreme and uncontrollable circumstances” and wants ACOs to be treated equitably regardless of the extent to which their patient populations are affected by the pandemic.
• This includes limiting the downside risk of ACOs in Track 1+.
• ACOs that are required to increase their financial risk over the course of their current agreement will have the option to maintain their current risk level for next year, instead of being advanced automatically to the next risk level.

See updates on:

• CMS Suspends Accelerated Payment Program 
• CMS Payments for Uninsured Patients

CMS Suspends Accelerated Payment Program 

On April 23^rd, Congress allocated an additional $75 billion in COVID-19 provider relief grants (in addition to the 100 billion previously announced). On Sunday April 26^th, CMS suspended Advanced Payments to Medicare providers. The Advanced Payment Program allowed groups to request an accelerated payment of 90-days’ worth of Medicare claims. CMS would recoup these payments over time.

This move surprised many providers. In a statement, the agency said, “CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through the Provider Relief Fund."

Since the Accelerated and Advance Payment Program was expanded on March 28^th, CMS said it has paid out roughly $100 billion in accelerated payments.

HHS has not yet announced how it plans to allocate the new $75 billion in new provider relief grant money from Congress.

CMS Payments for Uninsured Patients  

Health and Human Services (HHS) will reimburse providers for COVID-19 related services for uninsured patients dating back to February 4^th, 2020. This money will come out of the initial tranche of $100 billion allocated to healthcare in the CARES Act.

A new web portal will be available on May 6^th and providers can request reimbursement through this portal if they have treated or tested an uninsured patient for COVID-19.

HHS will reimburse providers at Medicare rates for these services as long as funding is available. Providers can claim reimbursement after they confirm the patient is uninsured, and if they agree not to balance bill the patient.

HHS expects to start reimbursement of these claims in the middle of May.

CMS had previously announced (on March 28^th) an expansion of its Accelerated and Advance Payment program as a result of COVID-19.

This program allows CMS to make a bulk pre-payment of 90 days’ worth of future claim revenue to help groups with cash-flow. CMS then recoups this money over time. More details can be found in our April 2^nd update.

CMS just announced they are expanding this program to help groups participating in CPC+ Track 1 and Track 2.

Essentially, eligible groups can now also request advanced payment of their 3rd quarter Care Management Fees.

The deadline to submit a request for these Care Management Fees is Tuesday April 28^th, 2020.

Importantly, for groups participating in CPC+, they should use the previously announced process for securing the advanced payment of their claims-based, fee-for-service revenue.

See additional information from AAFP.

See updates on:

• FQHC/RHC and Telehealth Billing Guidance
• MIPS Program and COVID-19 Clinical Trials
• New High Throughput Lab Codes

FQHC/RHC and Telehealth Billing Guidance

Telehealth Services: Defined as audio/visual communication with a patient.

• In the CARES Act, finalized on March 27^th, CMS encouraged utilizing more telehealth during the public health emergency (PHE).
• On April 17^th, CMS published more specific guidelines for exactly how RHC/FQHCs should bill for telehealth services, which are summarized below.
• CMS has set the payment for telehealth services at $92.00
• For telehealth services furnished between Jan 27^th, 2020 and June 30^th, 2020 groups should do the following:
  • Use modifier 95 on telehealth claims.
  • FQHCs will be paid based on their prospective payment system (PPS) rate.
  • RHCs will be paid at their all-inclusive rate (AIR).
  • CMS states these claims will be automatically reprocessed in July when CMS has updated its claims processing system with the new payment adjustment.
  • CMS states groups do not need to resubmit these claims for payment adjustment.
  • This is being positioned by CMS as an interim measure.
•  For telehealth services furnished starting July 1^st through the end of the PHE, groups should do the following:
  • Groups should use a RHC/FQHC specific G code (G2025) for telehealth services.
  • This new G code will be paid at a rate of $92.00.
  • Costs for furnishing these telehealth services will not be used to determine the RHC AIR or the FQHC PPS rates, but still must be reported on the appropriate cost report form.

Virtual Communication Services

• CMS previously provided details on virtual communication services, which were covered in our April 17^th update.
• Importantly, CMS did announce the new payment rate for G code G0071 (virtual communication services).
• Previously, the rate for G0071 was $13.53, it has been increased to $24.76.
• This fee increase is effective going back to March 1^st, 2020 and MACs will automatically reprocess G0071 claims that we not paid at this new rate. 

See additional information from CMS MLN.

Cost Sharing Waiver for COVID-19 Testing and Related Services—CS Modifier

• CMS confirmed that FQHCs and RHCs will benefit from the same cost waiver as traditional medical groups.
• CMS wants to eliminate financial barriers to patients being tested for COVID-19.
• As a result, patients do not have to pay a co-pay or co-insurance related to the actual testing, nor to the doctor’s visit (whether in-person or telehealth) that resulted in the test being ordered.
• CMS will pay 100% of these visits and tests.
• Groups must add a CS modifier when billing for these services.
• CMS states the MACs will automatically reprocess these claims beginning on July 1^st.

MIPS Program and COVID-19 Clinical Trials

• CMS had previously announced it was extending the deadline for 2019 data submission from March 31^st to April 30^th, 2020.
• MIPS eligible physicians that don’t submit their data by April 30^th will qualify for extreme and uncontrollable circumstances and will receive neutral payment adjustment for the 2021 MIPS payment year.
• CMS just announced new information regarding the MIPS program to encourage groups to participate in COVID-19 related clinical trials and to report their findings via a clinical data repository or data registry.
• Clinicians who report this activity will earn half of the total credit needed to earn the maximum score in the MIPS “Improvement” category. This category counts for 15% of the overall MIPS score.

New High Throughput Lab Codes

• CMS created two new healthcare common procedure coding system (HCPCS) codes (U0003 and U0004) to bill under Medicare Part B for clinical diagnostic laboratory tests that use high-throughput technologies to detect and diagnose the novel coronavirus.
• These codes are to be used for dates of service on/after March 18^th, 2020.
• CMS found that many labs aren't performing high-throughput tests because they're more complicated and expensive to process.
• By increasing the reimbursement, CMS hopes to speed the adoption of these new techniques.
• U0003 should identify tests that would otherwise be identified by CPT code 87635, but for being performed with these high throughput technologies.
• U0004 should identify tests that would otherwise be identified by U0002, but for being performed with these high throughput technologies.
• Neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies.

See updates on:

• Cost Sharing Wavier for COVID-19 Testing and Related Services—CS Modifier

• Telehealth Services for HCC Coding

• Reporting for HEDIS and CAHPS Measures

• Quality Reporting and MIPS Measures

• Telehealth Services for RHC and FQHC

• New AMA COVID-19 Testing Codes Effective April 10, 2020

Cost Sharing Waiver for COVID-19 Testing and Related Services—CS Modifier

• CMS wants everyone that should be tested, to be tested.

• CMS wants to eliminate financial barriers to patients being tested for COVID-19.

• As a result, patients do not have to pay any co-pay or co-insurance related to the actual testing, nor to the doctor’s visit (whether in-person or telehealth) that resulted in the test being ordered.

• The government wants to ensure the doctors get their full, normal payment so the insurers are paying 100% of these visits and tests.

• In order to get paid in full, groups must add a CS modifier when billing these services.

• Groups should work with their MAC on the process to rebill these services dating back to March 18^th.

See additional details from the American Academy of Family Physicians.

Telehealth services and HCC Coding

• On April 10^th, CMS announced they will allow telehealth visits to qualify for HCC risk adjustment during the Public Health Emergency.

• The remainder of the visit criteria for eligibility for risk adjustment remains the same.

• To qualify, the telehealth visit must be provided via an interactive audio and video telecommunications system that permits real-time interactive communication.

• These visits should follow CMS’s previously announced guidelines around using the traditional POS and the telehealth modifier “95”.

See additional details from a CMS bulletin.

Reporting of HEDIS and CAHPS Measures

• In an effort to reduce administrative burden and to allow focus on patient care, CMS has announced changes for the 2019 Measurement Year.

• The HEDIS submission requirement has been removed for the 2019 Measurement Year.

• CMS also removed the requirement for submission of the 2020 Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey for Medicare health and drug plans.

• CMS will use last year’s HEDIS measures scores and ratings from the 2020 Star Ratings (based on care delivered in 2018) for the 2021 Star Ratings.

• Similarly, CMS will use the CAHPS measures data scores and ratings (from the 2020 Measure-level Star Ratings) for the 2021 Star Ratings.

See additional details from a CMS bulletin.

Quality Reporting and MIPS Measures

• CMS had extended the deadline for 2019 data submission from March 31^st to April 30, 2020.

• MIPS eligible physicians that don’t submit their data by April 30^th will automatically qualify for extreme and uncontrollable circumstances and will receive neutral payment adjustment for the 2021 MIPS payment year.

Telehealth Services for RHC and FQHC

Telehealth Services: Defined as audio/visual communication with a patient.

CMS Telehealth

• CMS is encouraging more telehealth services to be provided during the PHE.
• CMS has yet to release the specific guidelines for exactly how to bill for telehealth services.
• We will update you as soon as the guidance is finalized.
•  

Medicaid Telehealth

• Some state Medicaid programs have provided guidance. While there are variations state-to-state, the general approach is:

  • Bill using T1015 plus appropriate CPT codes as normal

  • Add Modifier GT to indicate telehealth

  • Add Modifier CR to indicate catastrophe/disaster related

  • Use POS 02

Virtual Communication Services: These are not defined as telehealth as they are not performed using real-time audio/visual communication.

CMS

• CMS did provide details on Virtual Communication Services, which are covered below.

• Previously RHC and FQHCs could only bill for Virtual Communication Services (G0071) in a very limited set of circumstances.

• FQHCs and RHCs can now bill for Virtual Communication Services (HCPCS G0071). G0071 includes:

  • 5 minutes or more of virtual (non-face-to-face) communication between an RHC or FQHC practitioner and RHC or FQHC patient; or

  • 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner, occurring in lieu of an office visit; or

  • The services as described by CPT codes 99421-99423.

    • Online digital evaluation and management for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes, 11-20 minutes, or 21 or more minutes.

  • The services are no longer restricted to patients having prior treatment in the last year, allowing both new and established patients to benefit.

  • Consent for these services can now be obtained at the time of service.

• Effective for services furnished on or after March 1, 2020, CMS will revise the payment amount for HCPCS G0071 to reflect an average of the national non-facility payment rates for G2012, G2010, and 99421-99423.

Medicaid

• Again, state-to-state requirements vary, but in general the guidelines are:

  • Virtual Communication Services (99421-99423, G0071, 98966-98968) are reimbursable.

  • The POS for these services should be:

    • FQHC POS 50

    • RHC POS 72

  • Modifiers

    • These should be billed with Modifier CR (catastrophe/disaster related) to relax frequency limitations defined in the code definitions.

New AMA COVID-19 Testing Codes Effective April 10, 2020

• 86328: Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

• 86769: Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

See updates on:

• Interim Final Rule Updates on Telehealth
• Laboratory and COVID-19 Test Billing
• Information on ICD-10 Coding

Interim Final Rule Updates for Telehealth

• Telehealth Visits: Clarifying Guidance on Place of Service (POS) 02 vs Modifier 95

  • CMS is encouraging groups to provide telehealth services.

  • CMS has significantly expanded the types of services that can be provide via telehealth.

  • The technology required to perform these services has been broadened, however the requirement remains that the technology includes audio and visual. A phone call alone is not sufficient for a telehealth service.

  • CMS will be reimbursing physicians for these services at the same rate as an in-person visit.

  • CMS’s initial guidance was to use POS 02 for these telehealth visits.

  • Importantly, CMS has changed its position and now wants these new, expanded telehealth services to be billed in the following manner: 
    • The POS should be the place of service that would have been used if the patient had been seen face-to-face for telehealth visits.
    • Modifier 95 should be added to these telehealth services.
    • These changes ensure the payment is appropriately calculated based on the in-person rate.
• Reimbursement for Telephone Calls
  • Historically, CMS only reimbursed for telephone calls in very specific and limited instances.
  • CMS has modified its position on paying for telephone calls during the Public Health Emergency (PHE).
  • CMS will now reimburse groups for telephone calls for the services listed below.
  • These codes can now be billed for both new and established patients and can be used by providers, nurse practitioners, and physician assistants.

• • Modifier and POS Requirements:

    • Since these codes imply the use of communication technology to provide the service, there is no need for POS 02.

    • CMS recommends billing with the place of service that you would use for a face-to-face visit.

    • CMS will also allow reimbursement for telephone calls for registered dieticians, social workers, speech language pathologists and physical and occupational therapists.

    • These individuals should use the following codes:

• • Modifier and POS Requirements:

    • Since these codes imply the use of communication technology to provide the service, there is no need for POS 02.

    • CMS recommends billing with the place of service that you would use for a face-to-face visit.

• Virtual Check Ins

  • CMS will continue to allow and reimburse for Virtual Check Ins.

  • The policies around these codes remains largely unchanged, except they can be used for both new and established patients.

• • Modifier and POS Requirements:

    • CMS initially required place of service 02 (March 17^th).

    • Since these codes imply the use of communication technology to provide the service, there is no need for POS 02.

    • CMS recommends billing with the place of service that you would use for a face-to-face visit.

• Patient Communication via Patient Portal (CMS Defines these as E-Visits)

  • CMS will continue to reimburse for patient communications conducted via an on-line portal.

  • These services have largely remained unchanged as a result of the PHE.

  • The following codes are for physicians or other qualified health professionals:

  Code	Description	Non-Facility Rate
  99421	5-10 minutes	$15.52
  99422	11-20 minutes	$31.04
  99423	21-30 minutes	$50.16

   

• • The following codes are for qualified non-physicians (may not report E/M):

• • Modifier and POS Requirements:

    • CMS initially required place of service 02 (March 17th)

    • Since these codes imply the use of communication technology to provide the service, there is no need for POS 02.

    • CMS recommends billing with the place of service that you would use for a face-to-face visit.

•  Telehealth Services for RHC and FQHC

  • CMS is encouraging more telehealth services to be provided during the PHE.

  • Previously RHC and FQHCs could only bill for virtual communication services (G0071) in a very limited set of circumstances.

  • CMS is expanding the types of services that can be performed remotely to include those services covered by CPT codes 99421-99432 (E-Visits).

  • CMS will also revise the payment amount of G0071 to reflect this expansion of services and it will be paid at the average national non-facility amount for codes G2012, G2010, and 99421-99423.

  • All virtual communication services billable using code G0071 will also be available to new patients that have not been seen in the RHC or FQHC within the previous 12 months.

Updated Information on Laboratory and COVID-19 Test Billing

• CMS will reimburse medical groups that collect the throat swab for the purposes of collecting the specimen for sending to an outside lab for testing.

• Groups that perform these services can utilize one of these codes depending on the circumstances.

  • 99000- Handling and/or conveyance of specimen for transfer from office to a lab

  • 99001- Handling and/or conveyance of the specimen for transfer from the patient, in location other than a physician's office, to a laboratory.

  • 99211- Outpatient visit “that may not require the presence of a physician”

• CMS has also updated the Clinical Laboratory Fee Schedule to include two new codes for specimen collection: G2023 and G2024.

  • These codes are billable by clinical diagnostic laboratories that perform the specimen collection.

Updated Information on ICD-10 Coding

• CMS has announced guidance of ICD-10 coding for COVID-19 to try and ensure consistency in how diagnoses are being captured. This will help efforts to track and eventually research the disease.

• Up until April 1^st, CMS is recommending groups use the diagnosis code of B97.29 (other coronavirus as the cause of diseases classified elsewhere) for COVID-19.

• Effective April 1^st, the CDC is requesting groups use a newly developed ICD-10 code (U07.1) that is specific for COVID-19.

• This diagnosis code would be combined with other codes that more fully describe the patient’s condition. Examples include:

  • J12.89 (other viral pneumonia)

  • J20.8 (acute bronchitis due to other specified organisms)

  • J80 (acute respiratory distress syndrome)

  • J98.8 (other specified respiratory disorders)

• CMS is advising groups not to use B34.2 (coronavirus infection, unspecified) because COVID-19 is not unspecified.

• Additionally, official coding has been updated to include the recommendation that groups use the billable ICD-10 code Z11.59 to specify the diagnosis of encounters for screening the viral disease.

  • Specifically, this should be used when asymptomatic individuals who are being screened for COVID-19 and have no known exposure to the virus, and the test results are either unknown or negative.

CMS announced on March 28^th an expansion of its Accelerated and Advance Payment program as a result of COVID-19.

The expansion is part of the recently-enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act.

Accelerated and Advance Medicare payments was originally designed to address emergency funding of cash flow issues in areas where natural disasters have occurred.

During the COVID-19 crisis, CMS is expanding the program to include all Medicare providers and suppliers throughout the country.

The program allows CMS to make a bulk pre-payment of 90 days’ worth of future claim revenue to help groups with cash-flow. CMS then recoups this money over time.

At a high level, the program works like this:

1. The Medical Group/Hospital completes an application through their Medicare Administrative Contractor (MAC).

2. CMS makes a bulk payment of 3 months’ worth of typical CMS claim payments.

3. Groups continue to submit claims and get paid during the time of crisis (120 days)

4. Starting 120 days after the bulk payment, the group’s claims start being deducted from the amount of bulk payment.

5. This process of new claims being unpaid to offset the bulk payment will continue for 210 days for medical groups (longer for hospitals)

6. At the end of the 210 day timeframe, groups must repay the any outstanding balance in full at that time.

The specific details of the program are outlined in the Medicare Fact Sheet.

1. Continuing to expand and encourage the use of telehealth

• CMS will pay for 80 additional services when provided via telehealth.
• Importantly, CMS will now allow for evaluation and management services via audio-only phones.
• Allow practitioners to render telehealth services from their home, without reporting their home address on their Medicare enrollment, while continuing to bill from their currently enrolled location.
• Allowing “virtual check-ins” with physicians to be provided to new, as well as established patients.
• Allowing clinicians to provide remote patient monitoring services for acute conditions, whether for COVID-19 or for another condition.
• Allowing telehealth to fulfill many face-to-face visit requirements for patients in IRFs, home health and hospice.
• Allowing a physician determination that a Medicare beneficiary should not leave home because of a medical reason or COVID-19 to satisfy the home health “homebound” requirement.
• Allowing hospice recertifications to be completed via telehealth, rather than a face-to-face visit.
• Supervision of medical residents can be performed virtually.

2. Allowing more flexibility in treatment location

• Allow hospitals, critical access hospitals (CAHs), and inpatient psychiatric facilities (IPFs) to screen patients at an offsite location, so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan.
• Hospitals can change the status of their current provider-based department locations to address the needs of hospital patients as part of the state or local pandemic plan.
• Permit non-hospital buildings/space to be used for patient care and quarantine sites, provided that the location is approved by the state and not inconsistent with a state’s emergency preparedness or pandemic plan.
• Modify the requirement that a Critical Access Hospital (CAH) be located in a rural area or an area being treated as being rural, allowing the CAH flexibility to establishment surge site locations.
• Medicare will remove restriction on the “nearest location” and cover ambulance transportation to all destinations, from any point of origin, that are equipped to treat the condition of the patient.
• Hospitals can bill for services that are performed outside their four walls, such as directing patients via telehealth to offsite screening locations.
• Physician-owned hospitals can temporarily increase their number of beds, ORs, and procedure rooms.
• Hospital EDs can perform COVID-19 tests at drive-through testing sites.
• Hospitals can triage patients in state-approved community settings in a “hospitals without walls” model, such as ambulatory surgery centers, hotels, and dormitories.
• Hospitals can contract with ASCs to provide essential surgeries, for which Medicare will pay hospital rates.
• COVID-19 testing can be performed in homes, dedicated testing sites, and other community settings.

3. Expanding the healthcare workforce

• Waiving requirements that out-of-state practitioners be licensed in the state where they are providing services when they are licensed in another state. Note: CMS cannot waive state or local licensure requirements. As such, the state also would have to waive its licensure requirements.
• Waiving requirements to allow for physicians whose privileges will expire to continue practicing at the hospital and for new physicians to be able to practice before full medical staff/governing body review.
• Amending the teaching physician regulations to allow a teaching physician to provide supervision by interactive telecommunications technology, including when the medical resident is quarantined at home.
• Waiving requirements that a certified registered nurse anesthetist (CRNA) is under the supervision of a physician.

4. Relaxing Stark (Anti-Kickback) Regulations

• CMS issued 18 waivers from sanctions under the Stark/Physician self-referral law that address a wide array of specific types of transactions or referrals related to COVID-19
• CMS makes clear that items and services delivered on the basis of a referral permitted under the waivers are reimbursable under the program must be solely related to “COVID-19 Purposes.”
• This includes:
  • Diagnosis or medically necessary treatment of COVID-19 for any individual, whether or not the individual is diagnosed with a confirmed case of COVID-19.
  • Ensuring the ability of health care providers to address patient and community needs due to the COVID-19 outbreak in the United States.
  • Expanding the capacity of health care providers to address patient and community needs due to the COVID-19 outbreak in the United States.
  • Shifting the diagnosis and care of patients to appropriate alternative settings due to the COVID-19 outbreak in the United States.
  • A hospital can provides meals, comfort items (for example, a change of clothing), or onsite childcare with a value greater than $36 per instance to medical staff physicians who spend long hours at the hospital during the COVID-19 outbreak in the United States.

COVID-19 Impact on Billing and Coding Policies

4/2/20 Updates Include:

• The latest Telehealth guidelines
• CMS’s new Advanced Payment Option
• CMS’s efforts to expand hospital capacity

RCxRules has been closely monitoring the COVID-19 outbreak. We continue to have great appreciation for all that our customers are doing to help their patients and their communities. We are trying to do our small part by focusing on COVID-19’s impact on physician group’s billing and coding practices.

This is the first in a series of communications that we'll be distributing on this topic.

This communication is broken into two parts:  

1. What is CMS doing in response to COVID-19?

2. How does the CMS response impact billing and coding?

What is CMS doing in response to COVID-19

As a result of COVID-19, CMS has responded in several ways. At a high level, CMS is attempting to do the following:

1. Track and monitor the number of COVID-19 tests being performed.
2. Increase the use of Telehealth services to reduce the chance of the virus spreading in medical offices.
3. Reduce cost barriers to patient testing in order to encourage patients to seek care.
4. Track the prevalence of the virus (for current and future research) through consistent ICD-10 coding guidelines.
5. Expand hospital capacity
6. Ensure financial viability of healthcare providers

How does the CMS response impact billing and coding?

Outlined below are more details on the specific actions CMS has taken to support each of these objectives.

1. Track and monitor the number of COVID-19 tests being performed.

   CMS and the AMA are introducing new codes on April 1^st that should be used going forward and can also be used for dates of service going back to Feb 4^th for HCPCS and March 13^th for the CPT code.  

   • CMS HCPCS Codes
     • U0001- COVID-19 Testing through CDC Test
     • U0002- COVID-19 Testing through non-CDC Test  
   • AMA CPT Code
     • 87365- COVID-19 Testing DNA, RNA, Amplified Probe Technique

   Organizations providing the laboratory services should use these codes for all COVID-19 tests.

2. Increase the use of Telehealth services to reduce the chance of the virus spreading in medical offices.

   Effective on March 6^th and continuing during the COVID-19 crisis, CMS has increased payment and removed restrictions on the Telehealth visits.
   • CMS will eliminate the previous restrictions on the types of visits, the location, and the rural area designation that were previously associated with Telehealth payments.
   • Physicians will be allowed to conduct Telehealth visits, in lieu of a traditional office visit, on a broad range of services that are defined by CMS. On March 30^th, CMS added an additional 80 types of visits that are allowed via Telehealth. 
   • CMS will now pay for these Telehealth services at the same rate as traditional in-person visits. 
   • During this time period, CMS will reduce some HIPAA restrictions on the technology that can be used for a Telehealth visit. Technologies such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, and Skype are among the technology’s physicians may use during this period.
   • Also on March 30^th, CMS determined that a phone call with a patient would be considered a Telehealth visit and follow the same reimbursement guidelines as a video-based visit.

3. Reduce cost barriers to patient testing in order to encourage patients to seek care.

   CMS is waiving the patient’s responsibility for coinsurance and deductibles for COVID-19 tests.

   CMS is also waiving the patient’s responsibility for coinsurance and deductibles for the medical visit that resulted in the test being ordered.

4. Track the prevalence of the virus (for current and future research) through consistent ICD-10 coding guidelines.

   • Up until April 1^st, CMS is recommending groups use the diagnosis code of B97.29 (other coronavirus as the cause of diseases classified elsewhere) for COVID-19
   • This diagnosis code would be combined with other codes that more fully describe the patient’s condition. Examples include:
     • J12.89 (other viral pneumonia)
     • J20.8 (acute bronchitis due to other specified organisms)
     • J80 (acute respiratory distress syndrome)
     • J98.8 (other specified respiratory disorders)
   • CMS is advising groups not to use B34.2 (coronavirus infection, unspecified) because COVID-19 is not unspecified.
   • Effective April 1^st, the CDC is requesting groups use a newly developed code specifically for COVID-19. This new, specific ICD-10 code that is U07.1

5. Expand hospital capacity.

   • CMS will temporarily expand the types of facilities and locations that can perform essential services that were previously restricted. This includes ambulatory surgery centers, physician-owned hospitals, and non-traditional care settings.
   • CMS is also minimizing credentialing obstacles to the hiring of additional clinicians to meet the volume demands.

6. Ensure financial viability of healthcare providers.

   • CMS will allow groups to request a pre-payment of 90 days' worth of Medicare Claim volume to be paid in a lump sum (Accelerated and Advanced Payment option). After the crisis period has past, the groups will see an offset to their normal claim volume payments until the lump sum has been recouped. 

We are certainly living in challenging and uncertain times.

While the outbreak of COVID-19 is impacting everyone, the two groups most powerfully impacted are the patients with the virus and healthcare organizations caring for them.

On behalf of the entire RCxRules team, I want to thank you for everything you and your organization are doing to help this country navigate this crisis. We are fortunate to have the best healthcare delivery system in the world. Sometimes, as citizens, we may take this for granted. In light of current events, everyone should be grateful and appreciative of the skill and dedication of the care teams across the country. Our industry has risen to challenges before, and I remain optimistic we will meet this challenge, as well.

At RCxRules, we plan on doing our part to continue to support you through this difficult time. The vast majority of our Support Services are already delivered remotely. As a result, our Service team staffing, our technical infrastructure, and our Product Development operations position RCxRules well for normal operations. We will continue to monitor this developing situation with a strong focus on providing the highest level of support and service.   

In so many ways, healthcare workers are on the front lines and will be foundational to getting us through this crisis. Thank you very much for all you are doing. We truly appreciate it.

Stay safe.

Sincerely,

Stephen C Gorman