MEDICAL BILLING BLOG

For COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies and other immunizers will be $40 per dose.

This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines, and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses.

The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.

This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff.

At a time when vaccine supply is growing, Centers for Medicare & Medicaid Services (CMS) is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.

CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.

Coverage of COVID-19 Vaccines

As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance or deductible. 

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.

Medicaid: State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the public health emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID-19 vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit at Toolkit.   

Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost- sharing during the public health emergency (PHE). Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates. 

Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

More information on Medicare payment for COVID-19 vaccine administration – including a list of billing codes, payment allowances and effective dates – is available at Vaccine Shot Payment.

More information regarding the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Requirements, and how the COVID-19 vaccine is provided at 100% no-cost to recipients is available at Provider Support.

Information on the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program is available at Covid-19 Uninsured. 

To view the complete Centers for Medicare & Medicaid Services (CMS) announcement, click Vaccine Payments. 

To contact CMS Media Relations: (202) 690-6145 or CMS Media Inquiries.

About ClaimCare ®                        

ClaimCare has 30 years of medical billing experience. We have an established 100% USA-Based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition. 

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

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On February 26, 2021, the Centers for Medicare & Medicaid Services (CMS), together with the Department of Labor and Department of the Treasury, issued new GUIDANCE that removes barriers to COVID-19 diagnostic testing and vaccinations, and strengthens requirements that plans and issuers cover diagnostic testing without cost sharing.

This CMS guidance raises some key points and a few questions that need to be inspected by Healthcare Compliance Attorneys of providers/organizations involved with testing and vaccinations. With this blog post we are providing further details about the CMS guidance and we are highlighting questions that the affected providers/organizations need to have answered by your Healthcare Compliance/Billing Attorney.

Key Points and questions:

1. It is critical that individualized medical necessity screens remain in place.

• • This guidance document makes it clear that any testing done without “individualized clinical assessment” would be considered either public health surveillance or a job requirement and would not be required to be paid by insurance companies.

2. It is critical to get the interpretation of these new guidelines from a healthcare compliance and billing legal expert because there are some unclear areas in the guidelines. Specifically:  

• • On the one hand, the document says that payers cannot deny coverage of a COVID-19 test for lack of medical necessity. On the other hand, they say that payers must assume when they receive a claim that it reflects an "individualized clinical assessment." This seems to imply there has in fact been a medical necessity determination by a medical provider. 
     
    • If an "individualized clinical assessment" does imply the presence of a medical necessity, then how does the example of "I want to be sure I am COVID-19 free before seeing my parents" require such assessments to be modified so that a COVID-19 test is approved for reasons of this nature? 
  • The document seems to emphasize the importance of an individual seeking the test vs the test being required for Public Health Surveillance or employment. How does the distinction between a test being required interact with medical necessity of a test that is determined via an “individualized clinical assessment?” 

• • • If I am seeking a test because I need to show clear results to attend an optional event like a ballgame, a concert, a visit to a nursing home, a cruise, etc., then if prior to testing I have an “individualized clinical assessment” (e.g., a screening questionnaire), does that meet the criteria for a billable test since I am seeking the test so that I can attend an optional event AND I am receiving an individualized screening for medical necessity? These examples seem extraordinarily similar to the specific example given by CMS of an asymptomatic person with no know exposure having the COVID-19 test covered because the person wants  to visit a parent or relative.
    • If I need to have a clear test for my job AND I have an individualized medical necessity screen applied, is there any reason that the test cannot be billed to insurance if I show medical necessity through this “individualized clinical assessment?” Prior to this CMS clarification, payers had to cover a COVID-19 test when a medical necessity screen based upon symptoms or potential exposure warranted it. Does the fact that in some situations, such as “I want to visit my parents,” traditional medical necessity based upon symptoms or exposure risk seems to no longer be a requirement mean that a medical necessity screen can no longer be used to justify insurance billing of employee tests justified by exposure or symptoms and ordered via an “individualized clinical assessment?” In other words, has the medical necessity screen lost importance in determining if you can or cannot bill insurance for employees?  
  • Does any of this impact the wording of agreements that might be put in place with organizations requesting testing to help to ensure the language in the agreement does not run afoul of any of the public surveillance and employment testing exclusions?

 More Detail behind the points and questions above:

There are a few key areas on the CMS guidance document that prompted the questions I outlined above. As you can see on the document, there are 13 questions that are asked and answered. I spotlight Question 2 and the answer supplied by CMS:

Q2 – May plans and issuers distinguish between COVID-19 diagnostic testing of asymptomatic people that must be covered, and testing for general workplace health and safety, for public health surveillance, or for other purposes not primarily intended for individualized diagnosis or treatment of COVID-19?

Answer – Yes. Plans and issuers must provide coverage without imposing any cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements for COVID-19 diagnostic testing of asymptomatic individuals when the purpose of the testing is for individualized diagnosis or treatment of COVID-19. However, plans and issuers are not required to provide coverage of testing, such as for public health surveillance or employment purposes. But there is also no prohibition or limitation on plans and issuers providing coverage for such tests. Plans and issuers are encouraged to ensure communications about the circumstances in which testing is covered are clear. To the extent not inconsistent with the FFCRA’s prohibition on medical management, plans and issuers may continue to employ programs designed to detect and address fraud and abuse.

This is the section that prompts the questions about whether “individualized screening” moves a test form the public surveillance realm to the covered test realm. The concern is whether loosening the “medial necessity” guidelines apparently to allow individuals to have covered COVID-19 tests for any reason they deem necessary impacts the weight “individualized screening” has held in relation to COVID-19 testing up to this point in terms of justifying billing based upon medical necessity.

The answer below to Q1 in the guidance document is what creates the uncertainty between the purpose of “individualized clinical assessment” when reasons such as “visiting my parents” now are covered for testing.

“When an individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, or when a licensed or authorized health care provider refers an individual for a COVID-19 diagnostic test, plans and issuers generally must assume that the receipt of test reflects an  “individualized clinical assessment” and the test should be covered without cost sharing, prior authorization or any other medical management requirements.”

This statement is also what makes it critical that you have a screening that results in a "yes" where a doctor orders the test or a "no" where a doctor does not order the test. As long as the doctor does not order test for people that do not pass the screen then it should fall under the “individualized clinical assessment” point made above.

Finally, the document also emphasizes the importance of an “individualized clinical assessment” when it says test must be covered "...when a licensed or authorized healthcare provider administers or has referred a patient for such a test." 

Conclusion:

Obviously, this blog post poses more questions than it does clear guidance. However, as has been the case from the beginning of COVID-19, these situations are unprecedented. As such, the devil is in the “legal details.”

I would argue that all of this guidance means:

1. Medical necessity is still required,
2. The scope of medical necessity has expanded, and
3. As long as an individual screening for medical necessity is used, individuals meeting the new medical necessity guidelines are billable to insurance.

 What is far from clear is exactly how this guidance specifically expands the definition of “medical necessity.”

Thus, as emphasized in the beginning of this blog post, it is critical to obtain your Healthcare Attorney’s opinion on all the points and questions outlined in this post and in the CMS GUIDANCE document.

About ClaimCare ®                        

ClaimCare has 30 years of medical billing experience. We have an established 100% USA-Based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients. 

ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this recognition.

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

      100% USA-Based HIPAA-Compliant Medical Billing Company

CMS Seeks Faster COVID-19 Lab Results

CMS is working to ensure that patients who test positive for the virus are alerted quickly so they can self-isolate and receive medical treatment. Thus, under President Trump’s leadership, the Centers for Medicare & Medicaid Services posted an October 15 announcement of new actions to pay for expedited COVID-19 test results.

Back on April 15, CMS Administrator Seema Verma announced, “CMS has made a critical move to ensure adequate reimbursement for advanced technology that can process a large volume of COVID-19 tests rapidly and accurately.” At that time, Medicare payment to laboratories for high throughput COVID-19 diagnostic tests was increased from approximately $51 to $100 per test.

Now, to encourage labs to increase the rapidity in receiving results, beginning January 1, 2021, Medicare will pay $100 only to laboratories that complete high throughput COVID-19 diagnostic tests within two calendar days of the specimen being collected. Medicare will pay a rate of $75 to laboratories that take longer than two days to complete these tests, effective also on January 1, 2021.

“As America continues to grapple with the COVID-19 pandemic, prompt testing turnaround times are more important than ever,” said CMS Administrator Seema Verma. This updated payment announcement “supports faster high throughput testing, which will allow patients and physicians to act quickly and decisively with respect to treatment decisions, physical isolation, and contact tracing. President Trump continues to lead the most robust testing effort anywhere in the world.”

Amended Administrative Ruling (CMS 2020-1-R2)

This amended ruling, effective January 1, 2021, lowers the base payment amount for COVID-19 diagnostic tests run on high-throughput technology from $100 to $75 in accordance with CMS’s assessment of the resources needed to perform those tests.

Then, Medicare will make an additional $25 add-on payment to laboratories for a COVID-19 diagnostic tests run on high-throughput technology if the laboratory: (1) completes the test in two calendar days or less, and (2) completes the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month.

HCPCS Code U0005

CMS established these requirements to support faster high throughput COVID-19 diagnostic testing and to ensure all patients (not just Medicare patients) benefit from faster testing. These actions will be implemented under the amended Administrative Ruling (CMS-2020-1-R2) and coding instructions for the $25 add-on payment (HCPCS Code U0005) released October 15.

According to CMS, “The new payment amounts effective January 1, 2021 ($100 and $75) reflect the resource costs laboratories face for completing COVID-19 diagnostics tests using high throughput technology in a timely fashion during the Public Health Emergency."

Impact on Laboratories

This CMS update may have an impact on laboratories’ logistics and/or sample collections beginning with dates of service from January 21, 2021, forward. Please note that the two-day clock starts when the sample is COLLECTED, not when it is received by the lab.

It appears this updated policy is measured on a monthly basis. The two scenarios seem to be:

   1. In the prior month, the lab completes the majority of ALL COVID-19 tests (across all payers, not just Medicare) in 2 days or less from sample collection, and the two codes are billed: 
       a. COVID-19 test (U0004), which will pay $75
       b. Fast completion code (U0005), which will pay $25 

   2. In the prior month, the lab does not complete the majority of ALL COVID-19 tests (across all payers, not just Medicare) in 2 days or less from sample collection, and the one code is billed: 
       a. COVID-19 test (U0004), which will pay $75

Questions Will Be Asked

Undoubtedly, laboratories will have questions regarding this updated policy, and I feel sure additional information will be coming from CMS to answer such questions as:

1. What does “majority” mean? Simple majority? Super majority?  

2. Do both the test being billed AND the majority of tests from prior months need to be completed in two days or less? If you visit the CMS source, the text is not clear on this point.  

3. What if the issue is with the sample source and not with the lab when it comes to missing the two-day mark?

 When ClaimCare uncovers more information regarding this updated policy, we will posting it via our blogs.

__________________________

About ClaimCare ®                        

ClaimCare has 30 years of medical billing experience. We have an established 100% USA-based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to ClaimCare clients.

ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition.

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.

100% USA-Based HIPAA-Compliant Medical Billing Company

Just in case you are not already aware, this memo is to inform you the American Medical Association (AMA) added Current Procedural Terminology (CPT) code 99072, effective September 8, 2020, and has updated information about this code and other codes, which was posted September 22, 2020, on the AMA website in an article titled COVID-19 Coding and Guidance.

Coming rather late in the COVID-19 crisis, this code regards “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service when performed during a Public Health Emergency as defined by law due to respiratory-transmitted infectious disease.” 

CPT Code 99072 Explained

The earlier announcement explained Code 99072 is used to report additional practice expenses necessary in an office visit or other non-facility setting to mitigate the transmission of the respiratory disease for which the Public Health Emergency (PHE) was declared. These expenses include, but are not limited to, additional supplies such as face masks and cleaning supplies, as well as clinical staff time for activities such as pre-visit instructions and office arrival symptom checks that support the safe provision of evaluation, treatment or procedural services during the respiratory infection-focused PHE.

Instructions state that when reporting 99072, report only once per in-person patient encounter per day, per provider identification number, regardless of the number of services rendered at that encounter. Code 99072 may be reported during a PHE when the additional clinical staff duties as described are performed by the physician or other qualified health care professional in lieu of clinical staff.

Dollar Value To Be Established

This new code does not yet have any dollar value associated with it, but efforts are underway to establish payment. 

CPT Code 86413 Also Approved

As explained in the update, the AMA also approved CPT code 86413, which regards “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative," in response to the development of laboratory tests that provide quantitative measurements of SARS-CoV-2 antibodies.

Per the standard early release delivery process for CPT codes, note that the code descriptor will need to be manually uploaded into electronic health record systems. In addition to the long descriptor, codes 99072 and 86413 have short and medium descriptors that can be accessed on the above mentioned AMA Website.

For more detailed information on reporting codes 99072 and 86413, please refer to the September Update article on CPT Assistant, the official source for CPT coding guidance.

_________________________

About ClaimCare ® 

ClaimCare has 30 years of medical billing experience. We have an established 100% USA-based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition.

For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.