Administrative Guideline / Policy FAQ & Other Documents
The Healthcare Forum, a group representing payers and providers, formed a workgroup to address administrative issues related to the delivery of COVID-19 related healthcare, e.g. billing, pricing, reimbursement, etc.
- Identify pressing questions/issues/concerns related to COVID-19 Administration of Healthcare
- Quickly arrive at answers to common questions/issues/concerns. Highlight a common direction if one becomes apparent
- Broadly communicate answers, policies/positions and/or variations
FAQ ON COVID-19 HEALTH PLAN POLICIES, PROCEDURES & PRACTICES (LAST UPDATED 12/07/20)
As COVID-19 related questions arise from the provider community, they are presented to the Commercial and HCA-Apple Health Plans licensed in Washington State for their review and response. The Plans determine if they share a common direction on these questions, if so, it is reported with the question.
In addition to the question and any common direction, the documents below (complete set of questions/responses & individual questions/responses) contain, for each Plan,
- A short answer response, e.g. ‘Yes/No’ to how the Plan aligns with the common direction (along with the most recent date that the response was updates)
- A link to the Plan’s web site, along with navigation instructions as needed, where the most current and accurate information related to their policy/practice can be found,
- The Plan may list specific or related information relevant to their response that may not be on their web site.
These documents ARE NOT INTENDED to replace the information that is on the Plan’s web site. Each Plan’s web site is the location for their complete and accurate information. Rather these documents ARE INTENDED as a quick reference index for providers to know a) each Plan’s response and b) where the relevant information can be found on that Plan’s web site.
Section A: COVID Related Billing
Section A Question 1
For all patients that meet the CDC criteria, plans will cover 100% of the cost of COVID testing and Diagnostic Test Panels in an outpatient setting without patient deductible or cost share?
Section A Question 2
In situations where the testing is billed by the lab and the E&M visit is billed by the provider, how should providers submit the claim with the E&M visit -- so that it is clear that E&M visit is to be covered under the Emergency Order (since the testing will be billed by the lab)?
Section A Question 3
When do you anticipate that providers should submit claims to you for COVID testing?
Section A Question 4
If a claim was billed for COVID testing after the order (March 5th) and it was billed with an incorrect code, how should it be rebilled so that it is adjudicated under the order?
Section A Question 5
As provider organizations that do not have delegated credentialing bring on new providers to address the COVID demands, are there policies/practices under which the new provider can bill the health plan sooner rather than later?
Section A Question 6
When Remdesivir is used as an inpatient treatment with an appropriate COVID diagnosis...
a. Is it a covered service?
b. Does it require a prior authorization?
c. Are you following the ICD-10-PCS coding for Remdesivir (XW033E5, XW043E5)?
d. Are there special billing instructions?
e. Will it be reimbursed as an individual service or part of the DRG bundle?
Section A Question 7
Will your health plan make separate payment for PPE (and possibly additional clinical staff time) in addition to the reimbursement for the visit?
Section A Question 8
Will your health plan cover, before deductible and without cost share, the cost of the 2 new CPT codes for reporting laboratory tests (87636 and 87637 effective October 6, 2020) that simultaneously detect the COVID-19 virus, influenza A/B and respiratory syncytial virus?
Section B: Alternative Treatment Locations
Section B Question 1
Are ED services provided in tents and patient cars covered and if so, how should they be billed?
Section B Question 2
Are outpatient services provided in patient cars covered and if so, how should they be billed?
Section B Question 3
Are services provided by licensed hospitals in non-licensed space and/or non-licensed beds covered and if so, how should they be billed?
Section B Question 4
Is SNF care provided in a licensed hospital to COVID patients by hospitals in non-licensed beds covered and if so, how should they be billed?
Section C: Telehealth
Section C Question 1
Will a telemedicine visit for a care service be paid at the same rate as an in-person visit for that same care service?
Section C Question 2
Are you following the HHS guidelines for the methods that will be considered telehealth (e.g. SKYPE, Facetime, etc.)? How should they be billed?
Section C Question 3
What are your guidelines for audio only tele-services?
Section C Question 4
Will telehealth be a covered service for patients new to that provider?
Section C Question 5
For telehealth services during this interim period, will your plans allow the provider to select E&M code level based just on MDM OR on either MDM or time, with time defined as all of the time associated with the E/M on the day of the encounter?
Section C Question 6
Well child visits are not on the telehealth list from CMS. Will payers cover well child visits via telehealth?
These visits would occur where there isn't an immediate need for an in person visit and where immunization isn't required, Physicians are considering these for children over a certain age or meeting other criteria.
Section C Question 7
Under these circumstances will your health plan follow the CMS Guideline and allow the hospital to bill under the PFS for the originating site facility fee associated with the telehealth service as well as for the professional fee?
Section D: Provider Workflow
Section D Question 1
Will the outpatient pre-authorizations and pre-authorizations for scheduled elective admissions be extended longer than 90 days? If so, by how much?
Section D Question 2
Will health plans ease authorization requirements for key components of after-hospital care, such as admission to SNFs or rehab, providing home health visits, during this COVID period?
Section D Question 3
Can any patient signature requirements be waived for COVID patients, e.g. Medicare MOON?
Medicare and Federal Billing and Payment FAQ
This information has been compiled by the Washington State Hospital Association. WSHA will continue to augment and update this list of FAQs. Please contact Andrew Busz at firstname.lastname@example.org if you have questions that are not addressed here.
FEDERAL COVERAGE AND PAYMENT RELATED TO COVID-19
To what COVID-19 services does the federal prohibition on enrollee cost-sharing apply?
The Families First Coronavirus Response Act (FFCRA) requires that insurers cover services related to diagnostic testing for the detection and the diagnosis of COVID-19 without patient cost share (deductible, copay, or coinsurance). For more information see https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf. The requirement applies to Medicare and most group and individual insurance carriers and plans. See the Forum COVID-19 Work Group page for more information specific to other insurers. The provisions of the FFRCA and CARES acts do not address services provided to individuals that are not covered through insurance.
How can hospitals and providers be paid for services provided for testing and treatment of uninsured COVID-19 Patients?
The U.S. Health Resources and Services Administration (HRSA) launched a portal to reimburse providers for testing and treatment of uninsured COVID-19 patients. This coverage was authorized and funded through the FRCRA and CARES acts and applies to eligible services provided on or after Feb 4, 2020. Claims under the program will be paid at Medicare rates, subject to funding availability. Providers and hospitals receiving funds through the program will need to attest that they have verified the patient is not enrolled in public or private insurance, agree not to balance bill the patient for amounts in excess of the payment amount and agree to other terms and conditions. Read HRSA’s website and FAQs for more information.
What are the requirements for health care providers that received emergency funds from the CARES Act Provider Relief Fund?
Health care providers that receive funds must attest they agree to the terms and conditions of payment with 45 days of receipt of the funds. The terms and conditions are at https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/terms-conditions/index.html.
More information on the CARES Act Provider Relief Fund, including the attestation link is at https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html.
MEDICARE PAYMENT FOR COVID-19
What amount does Medicare pay for COVID-19 tests?
The Medicare allowed amount is $51.31 for CPT code U0002. CMS increased the payment amount for high throughput COVID-19 testing (codes U0003 and U0004) to $100 effective April 14. While the payment amounts are specific to Medicare, they may also impact payment for other payers that pay based on the Medicare fee schedule. For more information see our recent Fiscal Watch article.
How do I bill to receive higher Medicare payment for inpatient COVID-19 cases?
The CARES Act provided for a 20 percent add-on to the normal Medicare MSDRG rate for COVID-19 patients for the duration of the public health emergency. CMS states that it will identify discharges of an individual diagnosed with COVID-19 using the following ICD-10 diagnosis codes:
- U07.1 (COVID-19) for discharges occurring on or after April 1, 2020
- B97.29 (Other coronavirus as the cause of diseases classified elsewhere) for discharges occurring on or after Jan 27, 2020 and on or before March 31, 2020
Further coding guidance from the CDC is available for discharges on or after April 1 and prior to April 1.
For discharges with the diagnosis codes above, CMS will apply an adjustment factor to increase the DRG weight by 20% when determining inpatient PPS operating payments. Inpatient PPS claims for COVID-19 discharges on or after Jan. 27 that are received by CMS before April 21 will be automatically reprocessed to reflect the payment increase. Claims received on or after April 21 will be processed reflective of the 20% increase. Hospitals may need to resubmit claims for COVID19 patients if they did not include the appropriate diagnosis codes.
The CMS document is available here.
Sequester suspension: Is the suspension of the 2% sequester reduction based on May 1 date of service or date paid?
The additional 2% reduction is rescinded as of date of service May 1, 2020. There is no benefit to holding claims until after May 1.
Medicare Advantage and sequester suspension: Does the sequester reduction suspension apply to Medicare Advantage or only to original Medicare?
The sequester suspension applies to Medicare Advantage and the 2% reduction to payment is also stopped as of date of service May 1, 2020 for MA claims.
Rebilling of COVID-19 related services: Can hospitals rebill Medicare claims with COVID-19 diagnosis that were paid prior to passage of the legislation or MAC update? If so, what is the beginning date of service?
The unique ICD-10-CM for COVID-19 (U07.1) can only be used for services incurred on or after April 1. If you billed for a service on a COVID-19 patient on after April 1 that should have had the code, and it impacts payment, we recommend you submit a corrected billing. More information is in the CMS document here.
Use of DR and CR codes: For codes and services that require a DR or CR code, should it be applied to all claims for those services during the COVID-19 crisis or only those claims with a COVID-19 test or diagnosis?
It should be applied to any patient being treated for COVID (whether suspected or confirmed). It is not limited to testing.
Any additional information on billing of the CR and CR modifiers? It is hard for hospital coders to determine the circumstances to use the modifiers.
This is the information on the CMS COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing document:
General Billing Requirements
Regarding the use of the condition code “DR” and modifier “CR”, should these codes be used for all billing situations relating to COVID-19 waivers?
Yes. Use of the “DR” condition code and “CR” modifier are mandatory for institutional and non-institutional providers in billing situations related to COVID-19 for any claim for which Medicare payment is conditioned on the presence of a “formal waiver” (as defined in the CMS Internet Only Manual, Publication 100-04, Chapter 38, § 10). The DR condition code is used by institutional providers only, at the claim level, when all of the services/items billed on the claim are related to a COVID-19 waiver. The CR modifier is used by both institutional and non-institutional providers to identify Part B line item services/items that are related to a COVID-19 waiver. New: 4/10/20
TELEHEALTH FOR MEDICARE AND RHCS
What changes are there to Medicare telehealth and telemedicine coverage?
As a result of the COVID-19 crisis, many of the geographic restrictions to telehealth and telemedicine have been waived for the duration of the COVID-19 emergency and has dramatically increased the number and types of providers than can provide and bill for telehealth services as distant providers. It has also expanded the allowable technologies to include common technologies for audiovisual interaction such as Zoom and allow telehealth services to be provided to new as well as established patients. CMS documents are available here and here.
Will CMS expand the types of hospital-based providers (such as PT, OT, pharmacist consultations for blood thinner management, diabetic counselors) that can bill Medicare as distant telehealth providers?
The CMS interim rule expanded the types of providers that can bill telehealth as distant providers to include all providers that can bill under Medicare. The payment would reflect the professional components of the Medicare professional fee schedule. More information is available in the press release and CMS Fact Sheet.
Can hospitals bill a facility charge for telehealth services?
The interim rule also allows hospitals to bill and be paid for facility overhead for distant telehealth services. In these cases, the patient’s home is considered an outpatient department of the hospital. The hospital would be paid at the “originating site” fee under CMS PFS rather than the normal facility payments. Some hospitals have expressed concern on whether conditions of participation for hospital departments would be applied to services at the patient’s home. WSHA is are seeking additional information and will make that available when it is received.
How do Rural Health Clinics bill and get paid for distant telehealth services?
Rural health clinics were designated as approved providers of distant telehealth services as a result of the CARES Act passed March 27, 2020 and are eligible to receive payment for distant telehealth services from January 27 through the end of the COVID-19 emergency period. The payment amount is $92 per visit. For services submitted prior to July 1, 2020, services should be billed as normal encounters with a special modifier 95. Services submitted after July 1, 2020 should be billed with HCPCS code G2025. Beginning July, distant telehealth claims processed as encounters will be automatically reprocessed to reflect the $92 payment amount. For more information see the CMS Communication.