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COVID-19: Coverage & Reimbursement

MEDICARE

  • Medicare GME Affiliation Agreements: Two or more teaching hospitals may form a Medicare GME affiliated group to aggregate direct and/or indirect medical education resident caps to provide flexibility for cross-training residents. During the Public Health Emergency, teaching hospitals may have until Oct. 1, 2020 (rather than July 1, 2020) to submit new or amended Medicare GME affiliation agreements. As under existing procedures, hospitals should email new and/or amended agreements to CMS at Medicare_GME_Affiliation_Agreement@cms.hhs.gov and indicate in the subject line whether the Medicare GME affiliation agreement is a new one or an amended one. Copies must be sent to the hospitals’ MACs as well.

  • Medicare FFS Response to COVID-19: CMS provides updates through an MLN Article that covers guidance regarding delivering notices to beneficiaries; new specimen collection codes for clinical diagnostic laboratories billing for COVID-19 Testing; the ICD-10 diagnosis code information for COVID-19; a link to all the blanket waivers related to COVID-19; place of service coding guidance for telehealth claims; a link to the Telehealth Video for COVID-19; information on the waiver of coinsurance and deductibles for certain testing and related services; and information on the expanded use of ambulance origin/destination modifiers.

For Healthcare Providers

  • LTCH Policy: CMS recently confirmed that Medicare contractors will not calculate an average length of stay for LTCHs for cost reporting periods that include the COVID-19 public health emergency, which took effect March 1.
  • Guidance for Non-Federal Governmental Plans: On June 5, CMS released guidance for non-federal governmental plans implementing the Families First Coronavirus Response Act requirement to cover COVID-19 diagnostic testing and certain related items and services without cost-sharing, prior authorization or other medical management restrictions during the public health emergency. The guidance also covers the relaxed enforcement of certain timeframes related to group market requirements, and expanding and promoting access to telehealth options and prescription drugs during the outbreak.
  • Adjustments for Alternative Payment Models: On June 3, the CMMI announced several COVID-19-related modifications to current and future CMMI alternative payment models. The adjustments are captured in a summary table and are related to the models’ financial methodologies, quality reporting requirements and timelines. 
  • Medicare Condition Codes: On June 1, CMS clarified when to use the catastrophe/disaster-related modifier, as well as the disaster-related condition code, for Medicare claims submission. The resource includes a chart of when to use each code for waivers and flexibilities, and includes past code changes related to COVID-19.
  • CMS Alternate Care Site Payment Resource: On May 26, CMS released a fact sheet for state and local governments seeking Medicare, Medicaid or CHIP payment for inpatient and outpatient care provided at hospital alternative care sites during the COVID-19 emergency. The fact sheet covers hospital requirements, 1135 waivers, Medicare hospital enrollment and provider flexibilities.
  • FAQ On Price Transparency Requirement: Recently, CMS posted an FAQs document on the CARES Act requirement that providers of COVID-19 diagnostic tests make public the cash price for the tests on their website during the public health emergency. The document also notes that under the CARES Act and Families First Coronavirus Response Act, group health plans generally must reimburse providers of COVID-19 diagnostic tests at the negotiated rate or cash price, and cover certain COVID-19 diagnostic testing without cost sharing, prior authorization or other medical management requirements during the public health emergency.
  • COVID-19 Guidance on Medicaid Managed Care Plans: Recently, CMS issued new guidance to states to allow temporary COVID-19-related modifications in provider payment methodologies and capitation rates under Medicaid managed care plans. States would be allowed to use directed payments to increase provider payments within managed care arrangements. The AHA in its advocacy with CMS, requested many of the additional flexibilities regarding provider payment and capitation rates found in this new guidance to states. Read more details in this AHA Special Bulletin.

  • FAQs for State Medicaid and CHIP Agencies: On May 8, CMS issued a new FAQs document to aid the Medicaid program and CHIP in their response to the COVID-19 pandemic. The AHA issued a Special Bulletin with a summary of the key issues.
  • Health Plan Administrative Flexibilities: On April 21, CMS released FAQs on “Issuer Flexibilities for Utilization Management and Prior Authorization.”
  • CARES Act Provisions: On April 15, CMS released new guidance on certain provisions of the CARES Act. These provisions include: a Medicare add-on payment of 20% for both rural and urban inpatient hospital COVID-19 patients; a waiver of the LTCH site-neutral policy for COVID-19 patients; a waiver of the LTCH “50% Rule” for COVID-19 patients; and a waiver of the IRF “3-hour Rule” for COVID-19 patients.
  • SNF and Swing-Bed Services: CMS clarified in a new FAQ document on Medicare billing that the agency is waiving the Medicare coverage requirement for a three-day prior hospitalization requirement for both SNF and swing-bed services furnished by critical access hospitals and rural swing-bed hospitals.
  • Inpatient PPS Wage Index Occupational Mix Survey: CMS has extended the deadline to Aug. 3, 2020 for completed 2019 Occupational Mix Surveys, Hospital Reporting Form CMS-10079, for the Wage Index Beginning FY 2022, to be submitted to MACs.

  • FY 2020 IPF Pricer: CMS issued a notice on an update to the IPF Pricer software used in Medicare claims processing.
  • Medicare Payments for Diagnostic Tests: On April 15, CMS announced that Medicare will increase payment for certain “high-throughput” COVID-19 diagnostic tests to $100 to expand testing capacity and speed results during the public health emergency. 
  • Medicare FFS Claims: Section 3709 of the CARES Act suspends the 2% payment adjustment currently applied to all Medicare FFS claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through Dec. 31, 2020.
  • CMS Accelerated/Advanced Payment Programs:
    • On April 27, CMS announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program for all pending and new applications in light of direct payments made available through HHS’ Provider Relief Fund. In addition, CMS is suspending its Advance Payment Program to Part B suppliers effective immediately and is no longer accepting any new applications.
    • On April 9, CMS issued a News Alert announcing that the agency delivered more than $51 billion to healthcare providers on the frontlines battling COVID-19.
    • On April 3, the AHA issued an Advisory with updates and clarifications provided by CMS from a call held on April 2 with hospitals.
    • On March 28, CMS announced the expansion of the accelerated and advance payment program pursuant to the provisions of the CARES Act. View the CMS fact sheet for eligibility and process. Qualified providers requesting these payments will be required to submit the appropriate forms to their MAC, and each MAC will work to review and process payments within seven days of receipt of the request.
  • UnitedHealth Group Accelerated Payments: On April 7, UHG will accelerate nearly $2 billion in claims payments to U.S. healthcare providers under its fully insured commercial, Medicare Advantage and Medicaid businesses to address short-term financial pressure caused by the COVID-19 emergency, UnitedHealthcare and Optum announced. The insurer said it also will provide up to $125 million in small business loans to OptumHealth’s clinical partners.
  • Novitas Audits, Desk Reviews and Re-Openings: Novitas Solutions will be suspending requests for documentation for Medicare cost report activities for the following: 1) Cost report worksheet S-10 audits for all cost reports that begin during FFY 2018 for hospitals that qualify for disproportionate share hospital payment until May 15, 2020. As for any documentation requests that Novitas has already sent to facilities, it is extending the documentation due date to May 15, 2020; and 2) All Medicare desk reviews, audits and re-openings until May 15, 2020. Novitas will continue to work on any in-house desk reviews, audits and re-openings based on the documentation previously received. If additional information is needed to complete the reviews, Novitas will not send any information requests before May 16, 2020. Providers do not have to request an extension but will have this additional time if needed.

  • Expanded Coverage for Essential Diagnostic Services: On April 11, CMS and the Departments of Labor and the Treasury issued guidance regarding “the requirement for group health plans and group and individual health insurance to cover both COVID-19 diagnostic testing and certain other related services, including antibody testing, at no cost.

  • Anti-Kickback Sanctions Update: On April 3, the OIG issued a Policy Statement stating that OIG “will exercise its enforcement discretion not to impose administrative sanctions under the Federal anti-kickback statute” for many payments covered by the Blanket Waivers of the Stark self-referral law that CMS published last week. OIG’s statement applies to 11 of the waivers issued by CMS, including compensation for services personally performed by a physician, incidental benefits or loans provided to a physician.
  • 2021 MA and Part D Rate Announcement: On April 6, CMS published the CY 2021 Rate Announcement, finalizing Medicare Advantage and Part D payment methodologies for CY 2021. This Rate Announcement addresses comments received on Parts I and II of the CY 2021 Advance Notice, published on Jan. 6 and Feb. 5, 2020, respectively.
  • CARES Act Payments: On April 3, President Trump and HHS announced that the federal government will use a portion of the CARES Act’s $100 billion emergency fund to reimburse hospitals and healthcare providers for treating uninsured COVID-19 patients. In addition, on April 7, at a White House briefing, CMS Administrator Seema Verma announced that $30 billion from the CARES Act will be distributed this week through grants based on Medicare revenue. We are awaiting details regarding the distribution mechanics and methodology from CMS and will provide that information as soon as it’s available.
  • CMS Billing Update: On April 3, CMS released revised information on billing for professional telehealth distant site services, including allowing for more than 80 additional services, critical recommendations to nursing homes to help mitigate the spread of COVID-19, billing for multi-function ventilators (HCPCS Code E0467), and implementation of the ICD-10-CM diagnosis code, U07.1 for COVID-19, effective April 1. An updated ICD-10 MS-DRG GROUPER software package (V37.1 R1) to accommodate the new code is available on the CMS MS-DRG Classifications and Software webpage.
  • Medicare FFS Emergency-Related Policies and Procedures Without an 1135 Waiver: CMS FAQs (3/16/20)
  • Medicare FFS Emergency-Related Policies and Procedures With an 1135 Waiver: CMS FAQs (3/16/20)
  • Cost Report Extension: Novitas Solutions has approved an automatic extension in the normal cost report filing deadlines for the following fiscal year end (FYE) dates:
    • The filing deadlines of FYE Oct. 31, 2019 for cost reports due by March 31, 2020 and FYE Nov. 30, 2019 for cost reports due by April 30, 2020 have been extended to June 30, 2020.
    • The filing deadline of FYE Dec. 31, 2019 for cost reports due by June 1, 2020 has been extended to July 31, 2020.
  • Medicare Beneficiary Notice Delivery Guidance: CMS issued a list of Medicare beneficiary notices to beneficiaries receiving institutional care. Because of COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. CMS encourages the provider community to review all the specifics of notice delivery, as set forth in Chapter 30 of the Medicare Claims Processing Manual released on March 18.


TeleHealth

  • Telehealth Toolkit for Medicaid/CHIP: On April 23, CMS released a toolkit for states to more quickly adopt Medicaid and CHIP policies for telehealth use during the COVID-19 pandemic.


Billing and Coding Guidance

  • Diagnostic Laboratory Tests: MLN Connects published an article for physicians and non-physician practitioners regarding billing for clinician services as part of COVID-19 diagnostic lab tests. Specifically, for symptom and exposure assessment and specimen collection performed on and after March 1, 2020, CPT code 99211 should be used to bill for the assessment and collection provided by clinical staff (such as pharmacists) in conjunction with physician services, unless the physician is reporting another E/M code for concurrent services. This applies to all patients (not just established patients). The CS modifier must be submitted with 99211 (or other E/M code for assessment and collection) to waive cost sharing. Physicians should contact their MAC if they did not include the CS modifier when submitting 99211, so the MAC can reopen and reprocess the claim. CMS will automatically reprocess claims billed for 99211 that were denied because of place of service editing.
  • MLR Rebates to Enrollees: On June 12, CMS announced it will allow group and individual health plans to prepay their 2019 estimated medical loss ratio (MLR) rebate to enrollees to support continued coverage during the COVID-19 emergency. CMS also extended the deadline for submitting 2019 MLR Annual Reporting Forms to Aug. 17. The Affordable Care Act requires health insurance issuers offering group or individual coverage to issue an annual rebate to enrollees if their MLR is less than the applicable MLR standard.
  • Medicaid Testing & Uninsured Eligibility Group: Per the Families First Coronavirus Response Act and the CARES Act, Louisiana Medicaid has expanded coverage to include COVID-19 testing for uninsured individuals for the duration of the federally-declared public health emergency. Additional guidance is available in the Notice and on the LDH website. Informational Bulletin 20-5 has also been updated with the material contained in this notice.
  • Medicare Testing Payment Rates: On May 19, CMS said that until Medicare sets national payment rates for COVID-19-related testing claims, its MACs have authority to set payment amounts in their respective jurisdictions. The policy applies to claims received for newly-created HCPCS codes and includes two codes used by laboratories to bill for certain COVID-19 lab tests, including serology tests. There continues to be no cost-sharing with Medicare patients for these tests.

  • MLN Update for Therapy Codes: MLN issued an MLN Matters Therapy Codes Update containing updates to the list of codes that sometimes or always describe therapy services. The additions to the therapy code list reflect those made in calendar year 2020 for the COVID-19 public health emergency and include those collectively termed as Communications Technology-Based Services.
  • Coronavirus Specimen Collection Code: In a May 7, MLNConnects newsletter article, CMS announced that it established a new Level II HCPCS code for billing Medicare under the OPPS to identify and pay for specimen collection for COVID-19 testing. 
  • HCPCS Modifier Update: On April 24, CMS released an MLN Matters article regarding facilities that have a current CLIA certificate of waiver and that bill Medicare Administrative Contractors for services provided to Medicare beneficiaries.
  • CPT Codes for Antibody Testing: On April 10, the AMA released two CPT codes (86328 and 86769) for reporting antibody testing for the novel coronavirus, and revised its CPT code for SARS-CoV-2 nucleic acid tests (86318). Providers can manually upload the code descriptors into their electronic health record systems. The AMA created a document with additional guidance.
  • NUBC Guidance on Treatment Claims: On March 23, NUBC issued guidance identifying institutional claims related to COVID-19 treatment and the committee issued guidance on coding for hospitals utilizing off-campus testing locations.
  • Medicare FAQ: On March 23, CMS released an updated FAQs document on how to bill and receive payment for testing patients, telehealth and other in-home services
  • New COVID-19 CPT Code & Description for Testing: The new CPT code is effective March 13. 

Coverage Guidance

  • Cost-Sharing Modifier: In a clarification to previous guidance released on April 7, CMS will now waive cost-sharing (coinsurance and deductible amounts) under Medicare Part B for Medicare patients for certain COVID-19 testing-related services.
  • Medicare: Medicare is now covering COVID-19 testing when furnished to eligible beneficiaries by certified laboratories. These laboratories may also choose to enter facilities to conduct COVID-19 testing.

MEDICAID-FEDERAL


LOUISIANA MEDICAID/HEALTHY LOUISIANA

  • LDH Coverage Update: On June 3, LDH issued an update to Informational Bulletin 20-5 that includes coverage for serological antibody testing and conditions of that coverage.
  • Resumption of Hospital Utilization Management: Late last week, LDH updated Informational Bulletin 20-5 to reflect the resumption of utilization management by the Medicaid MCOs for hospital-based services. At the onset of the COVID-19 emergency, LDH had paused these activities to ensure that clinical personnel could be deployed where needed most.
  • LDH Continues to Update Informational Bulletin 20-5: LDH posted another update to Informational Bulletin 20-5 related to the ongoing COVID-19 emergency. The most recent changes include updated information related to the laboratory services fee schedule and procedure codes, the cessation of coverage for “telephone services” represented by CPT codes 99441-99443 as of June 1, 2020, and a clarification on reimbursement for telehealth services. This informational bulletin has been updated multiple times throughout the emergency, and we encourage hospitals to monitor these updates closely because of the coverage and reimbursement information contained therein. 
  • LDH Revised Bulletin: On May 15, LDH issued revised Informational Bulletin 20-5 with changes to the COVID-19 lab testing service code and fee schedule information, cessation of coverage for telephone services effective June 1, 2020, clarification related to reimbursement of certain telemedicine services, and updates related to pharmacy coverage. 
  • LDH Bulletin: Healthy Louisiana has revised Informational Bulletin 20-5 regarding Medicaid coverage for commercial lab testing for COVID-19. 
  • Billing and Claims Processing Guidance: On April 21, LDH revised Informational Bulletin 20-5 to reflect updated billing and claims processing guidance. 
  • LDH Laboratory Testing Fee Schedule: On April 16, LDH revised Informational Bulletin 20-5 to include a separate COVID-19 Laboratory Testing fee schedule, which contains information specific to the procedure codes, types of service, reimbursement, and effective dates of service for covered laboratory testing related to COVID-19. 
  • COVID-19 Healthy Louisiana Informational Bulletins: Healthy Louisiana has revised the following Informational Bulletins: IB 20-5-COVID-19-Provider Update; IB 20-6-COVID-19-Telemedicine /Telehealth Facilitation by Licensed Mental Health Practitioners; and IB 20-7-COVID-19-Telemedicine/Telehealth Facilitation of Outpatient Substance Use Disorder Treatment Services.
  • COVID-19 Provider Update: On April 3, LDH issued a revised version of Informational Bulletin 20-5 that included updated CPT code information for COVID-19 testing, clarified telehealth provisions and updated plan information, along with other guidance.
  • EHR Promoting Interoperability Applications: LDH has extended the deadline for Program Year 2019 EHR Promoting Interoperability applications to April 30, 2020. For questions and guidance on the application process, contact ehrincentives@la.gov
  • SUD-Telemedicine/Telehealth: On March 26, LDH issued Informational Bulletin 20-7 for Medicaid providers to deliver Outpatient Substance Use Disorder (OP-SUD) treatment services via telemedicine/telehealth for dates of service beginning on or after March 21, 2020, until rescinded by the Department.
  • LDH Health Plan Advisory: On March 14, LDH issued Health Plan Advisory 20-6 outlining several Medicaid provisions applicable to various aspects of the COVID-19 response 
  • Medicaid MCO Discharge Contacts Available 24/7:
    • ABH: Shelley Rodriguez; 504-473-6430
    • ACLA: Kursten Munson, Emelia Fernandez-Billiot, Stacey Nemeth, Lakeisha Higgenbotham and Rachel Weary; 225-300-9588;
    • HBL: Valerie Guidroz, Beth Rasch, Kelly Hebert and Brooke Deykin; 225-200-4751
    • LHCC: John Kight, DNP, RN; 318-261-9269;
    • UHC: Dr. Julie Morial; 504-220-0696; Julie_Morial_MD@uhc.com


ICD-10 RESOURCES

  • ICD-10-CM Code: On April 1, the CDC announced the official guidelines for the new ICD-10-CM code that goes into effect beginning on April 1 through Sept. 30. These codes will help capture and report surveillance data for the virus

OTHER MATERIALS

  • AHIP Actions: On March 23, America’s Health Insurance Plans Board of Directors outlined the actions that health insurance providers are taking to assist providers–particularly hospitals in the most affected, most at-risk communities.

QUICK LINKS

Louisiana Hospital Association

9521 Brookline Avenue, Baton Rouge, LA 70809  Google Map
Phone: (225) 928-0026
Fax: (225) 923-1004