Through the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (the CARES Act), cost-sharing for COVID-19 testing and related services has been waived for insured patients from March 18, 2020, through the end of the COVID-19 Public Health Emergency (PHE).
For providers billing these services to Medicare, the following billing guidelines will ensure Medicare pays 100 percent of the allowed amount rather than the typical 80 percent. While other payers do not have to follow the Medicare billing guidelines, coding consultant Betsy Nicoletti, in a recent CodingIntel article, recommends billing all payers using the same guidelines unless payers have specified differently.
For labs or other providers billing for COVID-19 tests, use one of the three codes available:
- U0001 – HCPCS code for COVID-19 tests developed by the Centers for Disease Control and Prevention (CDC)
- U0002 – HCPCS code for COVID-19 tests developed by labs other than the CDC
- 87635 – CPT code for COVID-19 tests
Use the appropriate HCPCS code for Medicare, and use either HCPCS or the CPT code for other payers depending on their billing guidelines. Also, add modifier -CS, which originally was used for the Gulf Oil Spill in 2010 but has been repurposed for COVID-19, to ensure cost sharing is waived.
Medicare will pay around $36 for the CDC tests, and the Centers for Medicare and Medicaid Serivces (CMS) announced this week that they will increase the amount Medicare pays for non-CDC tests to $100, up from $51.
CMS also updated guidance for implementation of the FFCRA and the CARES Act to ensure coverage of serological tests for COVID-19 used to detect antibodies, which suggest past COVID-19 infection and potential immunity.
Evaluation and Management Services
In addition to the COVID-19 test itself, FFCRA and the CARES Act require cost-sharing for provider visits, or evaluation and management (E/M) services, also be waived.
Cost-sharing for E/M services will be waived when the following conditions are met. The visit:
- was furnished between March 18, 2020 and the end of the Public Health Emergency (PHE);
- related to furnishing or administering a COVID-19 test or to the evaluation of an individual for purposes of determining the need for such a test;
- resulted in an order for or administration of a COVID-19 test;
- fell within the following categories of HCPCS evaluation and management codes:
- Office and other outpatient services
- Hospital observation services
- Emergency department services
- Nursing facility services
- Domiciliary, rest home, or custodial care services
- Home services
- Online digital evaluation and management services
- would result in payment to be made to one of the following:
- Hospital Outpatient Departments paid under the Outpatient Prospective Payment System
- Physicians and other professionals under the Physician Fee Schedule
- Critical Access Hospitals (CAHs)
- Rural Health Clinics (RHCs)
- Federally Qualified Health Centers (FQHCs)
As with the COVID-19 tests themselves, providers should add modifier -CS to any related claim lines to ensure Medicare pays at 100 percent. In addition, providers should add modifier -95 to any telehealth service lines that fit the above guidelines. (Learn more about billing telehealth in our recent article More Telehealth Flexibility for Billing Medicare.)
In addition to the COVID-19 test itself and the related office, hospital, or telehealth visit, any other services provided in order to determine the need for a COVID-19 test, such as an influenza test or other lab work, also should have cost-sharing waived. Just be sure to include modifier -CS to all related services.
A Few More Details
It’s important to note that the cost-sharing waiver is not limited to patients who test positive for COVID-19. Any patient who is suspected of COVID-19, and based on the clinician’s judgment needs to be tested for the novel coronavirus, should not pay for the test or related services.
Also, you cannot bill the patient for these services. If you do not receive 100 percent payment from payers, appeal the claim or resubmit using the -CS modifier.
For providers who have already submitted claims to Medicare for these services but did not include the -CS modifier, the Centers for Medicare and Medicaid Services (CMS) recommends the following:
- For professional claims, physicians and other practitioners who did not initially submit claims with the CS modifier should contact their Medicare Administrative Contractor (MAC) and request to resubmit applicable claims with the -CS modifier for 100 percent payment.
- For institutional claims, providers, including hospitals, CAHs, RHCs, and FQHCs, who did not initially submit claims with the CS modifier should simply resubmit applicable claims with the -CS modifier to get 100 percent payment.
To learn more about billing for COVID-19 testing and related services, review the following resources:
- “Modifier CS: Cost Sharing for COVID-19 Testing and Visits Related to Testing” from CodingIntel
- MLN Connects Issue 2020-04-10-MLNC-SE
- CMS’s COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing
- FAQS about Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation Part 42
- CIPROMS’ article, “Coding, Billing, and Paying for COVID-19 Testing”
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