COVID 19 – Medicare Payment Information for Providers

by | Last updated May 23, 2023 | Published on Mar 23, 2020 | Medical Coding

Medicare Payment Information for Providers
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The Corona virus pandemic is spreading to more and more countries, creating considerable panic and concern. According to The New York Times, the United States authorities have recently reported 306 cases of coronavirus and 17 deaths. With the rise in COVID-19 cases, providers as well as medical billing companies are confused about the reimbursement of the corona tests and treatments provided. The Centers for Medicare & Medicaid Services (CMS) recently issued an FAQ on COVID-19 that included clear details of Medicare payment for laboratory tests, and services provided by physicians, hospitals and ambulance services related to the 2019-Novel Coronavirus.

This COVID-19 FAQ pdf from CMS includes guidance on how to bill and receive payment for testing patients at risk of this infection, details of Medicare’s payment policies for laboratory and diagnostic services, drugs and vaccines under Medicare Part B, and also information on billing for telehealth or in-home provider services.

CMS’ COVID-19 Medicare Payment Guidelines

Lab Test Codes

Medicare Part B covers medically necessary clinical diagnostic laboratory tests when a doctor or other practitioner orders them. A laboratory can also bill for tests for COVID-19.

  • Starting in April, laboratories performing the laboratory test for COVID-19 can bill Medicare and other health insurers for services that occurred after February 4, 2020, using the newly created HCPCS code (U0001).
  • Laboratories performing non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19) can bill for them using a different HCPCS code (U0002). This code may be used for tests developed by certain laboratories in accordance with a new policy the Food and Drug Administration issued on February 29, 2020.

Payment for Physicians’ Services

Medicare pays for evaluation and management (E/M) and other services provided in a beneficiary’s home by a physician or non-physician practitioner (NPP).

    • Payment is also made for a number of non-face-to-face services including care management services, remote patient monitoring services, and communication technology-based services that helps to assess and manage a beneficiary’s conditions.
    • Medicare pays for several services that can be furnished via a number of communication technology modalities. Related codes include:HCPCS codes
      • G2012 (virtual check-in) can be furnished using synchronous technology such as a telephone call
      • G2010 (Remote evaluation of recorded video and/or images submitted by an established patient) can be furnished using asynchronous technology such as e-mail
      • G2061-G2063 Online Assessment by Qualified Non-physician Healthcare Professional HCPCS Code range

CPT code

    • 99421-99423 Non-Face-to-Face On-Line Digital Evaluation and Management Service
  • Payment for telehealth visits is currently limited to beneficiaries in certain types of healthcare facilities located in rural areas (originating sites). A beneficiary in a rural area cannot receive telehealth visits from their home except under certain exemptions.

Payment for Hospital Services

  • In case of an emergency, even in the absence of a 1135 waiver, a hospital may add a remote location that provides inpatient services, provided that the location satisfies the requirements to be provider-based to the hospital’s main campus, in addition to the Hospital Conditions of Participation (CoPs).
  • To be eligible for additional payment for rendering services to patients, a physician may certify or recertify the need for continued hospitalization if the case is that the patient could receive proper treatment in a skilled nursing facility (SNF), but no bed is available in a participating SNF. In such cases, the DRG rate will be paid and any cost outliers for the entire stay until the Medicare patient can be moved to an appropriate facility.
  • For hospitals that reimbursed under the Inpatient Prospective Payment System (IPPS), Normal prospective payment procedures apply. There is no special Diagnostic Related Group (DRG) for COVID-19.
  • When it comes to a Medicare psychiatric patient, if the patient is not in the Inpatient Prospective Payment System (IPPS) excluded IPF unit, even if the patient is a psychiatric patient, and as long as the placement of the patient in the hospital’s acute care bed is not inappropriate to his/her condition, the hospital will receive IPPS payment for that patient’s care. However, billing under the IPF unit’s provider number is not allowed.
  • There are cases where a patient needs to be isolated or quarantined in a private room to avoid infecting other individuals. Hospitals having both private and semiprivate accommodations may not charge the patient a differential for a private room, if the private room is medically necessary. If a Medicare beneficiary is a hospital inpatient for medically necessary care, Medicare will pay the DRG rate and any cost outliers for the entire stay until the Medicare patient is discharged. The DRG rate includes payment, if a patient needs to be isolated or quarantined in a private room.

Medicare Part B – Drugs and Medications

  • Medicare Part B pays for
    • Preventive Hepatitis B vaccinations for high-and intermediate-risk beneficiaries
    • Influenza and pneumococcal vaccinations for all Medicare beneficiaries
    • Medically necessary vaccinations of beneficiaries against a microbial agent or its derivatives (e.g., tetanus toxin, Hepatitis A)
  • Based on the current law, once a vaccine becomes available for COVID-19, Medicare will cover the vaccine under Part D. All Part D plans will be required to cover the vaccine.
  • Any new antiviral drugs covered under Medicare Part B can be paid by the Medicare Administrative Contractors until they receive a code and are on the pricing files. New drugs covered under Medicare Part D can be billed to the beneficiary’s Part D plan.
  • While handling billing for services that involve the use of Strategic National Stockpile (SNS) provided drugs, hospitals must remember that based on existing policy, providers may not seek reimbursement for no cost items such as SNS drugs.
  • While paying for a greater-than-30-day supply of drugs, MACs will take into account the nature of the particular drug, the patient’s diagnosis, the extent and likely duration of disruptions to the drug supply chain during an emergency, and other relevant factors that would be applicable when making a local determination as to whether, on the date of service, an extended supply of the drug was reasonable and necessary.
  • In the event of an emergency, local MACs may consider allowing payment for a medically necessary, greater-than-30-day supply of Medicare-covered, immunosuppressive drugs on a case-by-case basis taking local considerations into account.

Payment for ambulance services

  • Medicare law prohibits payment for an ambulance service unless the transport of a Medicare beneficiary has taken place. At the same time, a physician or NPP who furnishes their services from an ambulance, may bill for those services under the Medicare Physician Fee Schedule, assuming that the services furnished were in accordance with applicable state law and services are within his or her scope of practice requirements.
  • Medicare’s payment to ambulance suppliers and providers for ambulance transports includes payment for all necessary supplies, including oxygen, provided during the transport. So, if the transport is a Medicare-covered service, no separate payment for furnishing oxygen would be available.
  • Medicare can only pay for ambulance transportation when it meets the Origin and Destination Requirements and all other coverage requirements. These requirements specify that an appropriate destination is a Hospital, Critical Access Hospital (CAH), Skilled Nursing Facility (SNF), Beneficiary’s home or a Dialysis facility for ESRD patient who requires dialysis.
  • Medicare payments for health care services include the supplies necessary to appropriately provide the service, including any personal protective equipment and supplies suitable for the patient’s condition and treatment. There are not separate payments for those supplies.

Healthcare providers as well as medical billing outsourcing providers must be up to date with such instructions and regulations to fasten the reimbursement process.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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