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JM PART B MEDICARE ADVISORY Latest Medicare News for JM Part B What’s Inside...

AdministrationeServices: COVID-19 Transition ............................................................................................ 3 eServices and Google Authenticator ....................................................................................... 4 Get Your Medicare News Electronically ................................................................................ 6 ePass is Now Available to Ease the Burden of Repeated Authentication When Calling

Palmetto GBA’s Provider Contact Center ........................................................................... 8 eTicket Enables Providers to Save Time with Every Call ...................................................... 9 CMS Quarterly Provider Update .......................................................................................... 10 Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the

Coronavirus (COVID-19).................................................................................................. 12 Claim Status Category and Claim Status Codes Updates ..................................................... 29 2021 Annual Update for the Health Professional Shortage Area (HPSA) Bonus

Payments ........................................................................................................................... 31 Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04,

Chapter 26, Section 10.4, Item 19 ..................................................................................... 32 Update to the Medicare Claims Processing Manual ............................................................. 33

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)October Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics and

Supplies (DMEPOS) Fee Schedule ................................................................................... 34

EducationEducational Events Where You Can Ask Questions ............................................................. 39 Mactoberfest®........................................................................................................................ 41

Electronic Data Interchange (EDI)Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic

Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE ............................................. 45

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The JM Part B Medicare Advisory contains coverage, billing and other information for Part B. This information is not intended to constitute legal advice. It is our official notice to those we serve concerning their responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information and to follow the guidelines. The JM Part B Medicare Advisory includes information provided by the Centers for Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change at any time. This bulletin should be shared with all health care practitioners and managerial members of the provider staff. Bulletins are available at no-cost from our website at https://www.PalmettoGBA.com/JMB.

CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee sched-ules, relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2019 American Dental Association (ADA). All rights reserved.

October 2020 Volume 2020, Issue 10

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Medicine Annual Clotting Factor Furnishing Fee Update 2021 ...................................................................................................47 National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP) .........................48

Ambulatory Surgical Center (ASC) October 2020 Update of the Ambulatory Surgical Center (ASC) Payment System .....................................................51

Laboratory Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge

Payment .....................................................................................................................................................................57

Oncology National Coverage Determination (NCD 90.2): Next Generation Sequencing (NGS) for Medicare Beneficiaries with

Germline (Inherited) Cancer .....................................................................................................................................66

Skilled Nursing Facility (SNF) Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF)

Consolidated Billing (CB) Update ............................................................................................................................68

Etcetera Medical Director’s Desk ...............................................................................................................................................69 MLN ConnectsTM ........................................................................................................................................................139

CMS Provider Minute Videos

The Medicare Learning Network has a series of CMS Provider Minute Videos (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia) on a variety of topics, such as psychiatry, preventive services, lumbar spinal fusion, and much more. The videos offer tips and guidelines to help you properly submit claims and maintain sufficient supporting documentation. Check the site often as CMS adds new videos periodically to further help you navigate the Medicare program.

CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

2 10/2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimediahttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimediahttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Multimedia

eServices: COVID-19 Transition In light of the COVID-19 pandemic, organizations are proactively transitioning employees across the health care industry back into the office.

Palmetto GBA is providing a quick reference eServices guide to assist with common issues you may experi-ence if you have not logged into your eServices account in the past 30-60 days.

If you are not currently registered to use eServices, we have also included some resources to get you started.

Jurisdiction M: https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BQUPJ705&url=yes


3 10/2020

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BQUPJ705&url=yes

eServices and Google Authenticator

To enhance the security of Medicare information, the Centers for Medicare & Medicaid Services (CMS) requires the use of multi-factor authentication (MFA) each time you log in to eServices. We're excited to announce a new option to protect your account - Google Authenticator.

You now have three options to receive an MFA code: • Email • Text • Google Authenticator

Are you new to eServices? Or maybe you already have an eServices account...no worries! In just a few quick steps, you can set up Google Authenticator. This two-step verification is available when initially registering for eServices or if you already have an existing eServices account.

Initial Registration Upon initial registration to eServices, you must complete the fields on the MFA Setup screen.

The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google Authenticator option.

After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These steps are based on your device - iPhone or Android: • iPhone users must access iTunes • Android users must access Google Play

A successful installation prompts this screen showing your device is now linked. Select Submit to save the changes.

At your initial login to eServices, you are asked to choose your preferred method for receiving your MFA code.

Select the Use the app button to receive the MFA code via the Google Authenticator app.

Continued >> CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ©2019 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

4 10/2020

After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will renew every 30 seconds.

Enter the code in the available field and select the Submit button.

Existing Account At your next login to eServices, you are asked to choose your preferred method for receiving your MFA code.

You must choose from the text or email options since you haven’t set up the Google Authenticator option yet.

After verification, go to the My Account tab to change your account settings.

From the My Account tab, scroll down until you see the MFA Setup options.

The information entered on this screen will be saved in your profile. Select Authenticator Setup for Google Authenticator option.

After selecting the Authenticator Setup button, you'll see instructions for installing Google Authenticator. These steps are based on your device - iPhone or Android: • iPhone users must access iTunes • Android users must access Google Play

A successful installation prompts this screen showing your device is now linked. Select Submit to save the changes.

At your next login to eServices, you are again asked to choose your preferred method for receiving your MFA code. But not you’ll notice you can also choose to receive your code with the Google Authenticator app.

Select the Use the app button to receive the MFA code via the Google Authenticator app.

After selecting Use the app, the verification code will appear in your Google Authenticator app. This code will renew every 30 seconds.

Enter the code in the available field and select the Submit button.


5 10/2020

Get Your Medicare News Electronically The Palmetto GBAMedicare listserv is a wonderful communication tool that offers its members the opportunity to stay informed about: • Medicare incentive programs • Fee Schedule changes • New legislation concerning Medicare • And so much more!

How to register to receive the Palmetto GBA Medicare Listserv: Go to http://tinyurl.com/PalmettoGBAListserv and select “Register Now.” Complete and submit the online form. Be sure to select the specialties that interest you so information can be sent.

Note: Once the registration information is entered, you will receive a confirmation/welcome message informing you that you’ve been successfully added to our listserv. You must acknowledge this confirmation within three days of your registration.

eServices Eligibility eServices, by Palmetto GBA, allows you to search for patient eligibility, which is a functionality of HETS. HETS requires you to enter beneficiary last name and Medicare ID Number, in addition to either the birth date or first name. See options below:

• Medicare ID Number, Last Name, First Name, Birth Date • Medicare ID Number, Last Name, Birth Date • Medicare ID Number, Last Name, First Name

For more information about eServices and the many services it offers, please visit our website at http://www.PalmettoGBA.com/eServices.


6 10/2020

http://tinyurl.com/PalmettoGBAListservhttp://www.PalmettoGBA.com/eServices

Medicare Learning Network® (MLN) Want to stay informed about the latest changes to the Medicare Program? Get connected with the Medicare Learning Network® (MLN) – the home for education, information, and resources for health care professionals.

The Medicare Learning Network® is a registered trademark of the Centers for Medicare & Medicaid Services (CMS) and the brand name for official CMS education and information for health care professionals. It provides educational products on Medicare-related topics, such as provider enrollment, preventive services, claims

processing, provider compliance, and Medicare payment policies. MLN products are offered in a variety of formats, including training guides, articles, educational tools, booklets, fact sheets, web-based training courses (many of which offer continuing education credits) – all available to you free of charge!

The following items may be found on the CMS web page at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/index • MLN Catalog: is a free interactive downloadable document that lists all MLN products by media format. To

access the catalog, scroll to the “Downloads” section and select “MLN Catalog.” Once you have opened the catalog, you may either click on the title of a product or you can click on the type of “Formats Available.” This will link you to an online version of the product or the Product Ordering Page.

• MLN Product Ordering Page: allows you to order hard copy versions of various products. These products are available to you for free. To access the MLN Product Ordering Page, scroll to the “Related Links” and select “MLN Product Ordering Page.”

• MLN Product of the Month: highlights a Medicare provider education product or set of products each month along with some teaching aids, such as crossword puzzles, to help you learn more while having fun!

Other resources: • MLN Publications List: contains the electronic versions of the downloadable publications. These products

are available to you for free. To access the MLN Publications go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications. You will then be able to use the “Filter On” feature to search by topic or key word or you can sort by date, topic, title, or format.

MLN Educational Products Electronic Mailing List To stay up-to-date on the latest news about new and revised MLN products and services, subscribe to the MLN Educational Products electronic mailing list! This service is free of charge. Once you subscribe, you will receive an e-mail when new and revised MLN products are released.

To subscribe to the service: 1. Go to https://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-l and select the ‘Subscribe or

Unsubscribe’ link under the ‘Options’ tab on the right side of the page. 2. Follow the instructions to set up an account and start receiving updates immediately – it’s that easy!

If you would like to contact the MLN, please email CMS at [email protected].


7 10/2020

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/indexhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.Youhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.Youhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications.Youhttps://list.nih.gov/cgi-bin/wa.exe?A0=mln_education_products-lmailto:[email protected]

ePass is Now Available to Ease the Burden of Repeated Authentication When Calling Palmetto GBA’s Provider

Contact Center Authentication is required before Palmetto GBA is authorized to discuss Medicare information with a provider. The ePass is an eight-digit code providers can elect to receive, per each NPI and PTAN combination, following their first-time authentication when they call the Provider Contact Center (PCC). This ePass can then be used for the remainder of the day in order to authenticate. This code will be delivered in one of two ways: • Through the IVR, follow the first-time authentication steps by selecting Option 5 for ePass and then Option

2 to receive ePass; or • Request your ePass verbally while speaking with a Customer Service Agent (CSA) following first-time

authentication

The goal of the ePass is to ease provider burden by eliminating the need to repeatedly authenticate each time you contact the PCC in a given day. The ePass can then be used for the remainder of that business day in order to authenticate. Simply select Option 5 for ePass and Option 1 to enter your 8-digit ePass number.

This enhancement is in direct response to provider feedback with the goal of improving your provider experience with Palmetto GBA.


8 10/2020

eTicket Enables Providers to Save Time with Every Call Palmetto GBAcontinues to develop tools to improve service and efficiency, and our new eTicket is no exception.

eTicket, like the recently introduced ePass, will save you time when contacting the Provider Contact Center (PCC) about a particular issue on multiple occasions. While ePass provides you with a code to bypass authentication on subsequent calls to the PCC during a single day, eTicket enables our representatives to serve you quickly and with greater effectiveness.

When you speak to a customer care representative by phone, a numeric inquiry number or eTicket is generated which provides a reference to the subject matter of your conversation with our PCC. When you call us with additional follow-up questions or for more information specific to a prior call, you can input your eTicket number into the IVR. Upon being transferred to a service representative, your topic of inquiry and data related to your previous call with Palmetto GBA will automatically be presented on the service representative’s screen, expediting their ability to serve you.

Palmetto GBA welcomes you to eTicket. Look for additional information at www.PalmettoGBA.com, in our Listserv newsletters and on Palmetto GBA’s social media channels.


9 10/2020

http://www.PalmettoGBA.com

CMS Quarterly Provider Update The Quarterly Provider Update is a comprehensive resource published by the Centers for Medicare & Medicaid Services (CMS) on the first business day of each quarter. It is a listing of all non-regulatory changes to Medicare including program memoranda, manual changes and any other instructions that could affect providers. Regulations and instructions published in the previous quarter are also included in the update. The purpose of the Quarterly Provider Update is to: • Inform providers about new developments in the Medicare program • Assist providers in understanding CMS programs and complying with Medicare regulations and instructions • Ensure that providers have time to react and prepare for new requirements • Announce new or changing Medicare requirements on a predictable schedule • Communicate the specific days that CMS business will be published in the ‘Federal Register’

To receive notification when regulations and program instructions are added throughout the quarter, sign up for the Quarterly Provider Update listserv (electronic mailing list) at https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566.

We encourage you to bookmark the Quarterly Provider Update Web site at www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index and visit it often for this valuable information.

eServices Extends Administrator Unlock Feature Beyond 30 Days Palmetto GBA has implemented new “Disable User” functionality in eServices that will disable a user that has been inactive for 30 days instead of terminating the User ID. Administrators will now be able to enable the user up to 120 days after 30 days of inactivity. If the user ID is not enabled within this time, the account will be terminated. We will send notification to providers through a series of periodic emails (up to the 120-day limit) to remind the user of their status and provide instructions to re-enable eServices IDs.

In short, provider administrators can now simply unlock users as well as other administrators. This is a significant change from past guidelines. Previously: • Provider Administrators and users were required to login at least once every 30 days

• Accounts in which users did not login past 30 days were deactivated/terminated • If the provider admin did not login, all user accounts associated with the provider admin were also

deactivated/terminated • This created additional work for administrators as they were required to create new accounts for deactivated/

terminated users

The Provider Contact Center eServices Helpdesk is also able to assist if the provider administrator is unable to complete this task.


10 10/2020

https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&qsp=566http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/QuarterlyProviderUpdates/index

You Can Track Your Enrollment ApplicationPalmetto GBA makes it easy for you to track your enrollment application with our Application Status Lookup Tool. This tool provides tracking data for application types 855A, 855B, 855I, 855R and 855O, and Medicare Diabetes Prevention Program. Additionally, the tool will provide updates on submitted CMS 588 (EFT), CMS 460 (Participating Agreement), reconsideration requests, opt-out affidavits, license updates and voluntary terminations requests. • Jurisdiction J, Part B:

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQEN88&url=yes • Jurisdiction M, Part B:

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQGS18&url=yes


11 10/2020

https://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQEN88&url=yeshttps://www.palmettogba.com/internet/PCIDN.nsf/R?OpenAgent&DID=BBHQGS18&url=yes

Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)

MLN Matters Number: SE20011 Revised Article Release Date: August 26, 2020 Related CR Transmittal Number: N/A Related Change Request (CR) Number: N/A Effective Date: N/A Implementation Date: N/A

Note: We revised the article to add information about the HCPCS codes for OPPS, RHC, FQHC, and CAH billers in the Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services section. All other information remains the same.

Provider Types Affected This MLN Matters® Special Edition Article is for physicians, providers and suppliers who bill Medicare Fee-For-Service (FFS).

Provider Information Available The Secretary of the Department of Health & Human Services declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020 Secretary Azar authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020.

The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. These waivers prevent gaps in access to care for beneficiaries impacted by the emergency. You do not need to apply for an individual waiver if a blanket waiver is issued.

More Information: • Coronavirus Waivers and Flexibilities

(https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/ coronavirus-waivers) webpage

• Instructions (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf) to request an individual waiver if there is no blanket waiver

Background Section 1135 and Section 1812(f) Waivers As a result of this PHE, apply the following to claims for which Medicare payment is based on a “formal waiver” including, but not limited to, Section 1135 or Section 1812(f) of the Act: 1. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC

X12 837 institutional claims format or paper Form CMS-1450. 2. The “CR” (catastrophe/disaster related) modifier for Part B billing, both institutional and non-

institutional, i.e., claims submitted using the ASC X12 837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP format.


12 10/2020

https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivershttps://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivershttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Requesting-an-1135-Waiver-Updated-11-16-2016.pdf

Clarification for Using the “CR” Modifier and “DR” Condition Code When a PHE is declared and section 1135 authority is invoked, CMS has the authority to take proactive steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Act, to approve blanket waivers of certain Social Security Act requirements. These waivers help prevent gaps in access to care for beneficiaries impacted by the emergency. In previous emergencies, CMS issued a limited number of waivers for the Medicare Fee-for-Service program. In order to allow CMS to assess the impact of prior emergencies, CMS has required the use of modifier “CR” and condition code “DR” for all services provided in a facility operating pursuant to CMS waivers that typically were in place, for limited geographical locations and durations of time.

For the COVID-19 PHE, CMS has issued many additional blanket waivers, flexibilities and modifications to existing deadlines and timetables that apply to the whole country. The full list of waivers and flexibilities can be found here. Due to the large volume and scope of these new blanket waivers and flexibilities, CMS is clarifying which require the usage of modifier “CR” or condition code “DR” when submitting claims to Medicare. The chart below identifies those blanket waivers and flexibilities for which CMS requires the use of the modifier or condition code. Submission of the modifier or condition code is not required for any waivers or flexibilities not included in this chart.

Please note that CMS will not deny claims due to the presence of the “CR” modifier or “DR” condition code for services/items related to a COVID-19 waiver that are not on this list, or for services/items that are not related to a COVID-19 waiver. There may be potential claims implications, such as claims denials, for claims that do not contain the modifier or condition code as required in the below chart. However, providers do not need to resubmit or adjust previously processed claims to conform to the requirements below, unless claims payment was affected.

Waiver/Flexibility Summary CR DR Care for Excluded Allows acute care hospitals with excluded distinct part inpatient Inpatient Psychiatric psychiatric units to relocate inpatients from the excluded distinct Unit Patients in the part psychiatric unit to an acute care bed and unit as a result of a X Acute Care Unit of a disaster or emergency. Hospital Housing Acute Allows acute care hospitals to house acute care inpatients in Care Patients in the excluded distinct part units, such as excluded distinct part unit IRFs IRF or Inpatient Psychiatric Facility

or IPFs, where the distinct part unit’s beds are appropriate for acute care inpatients. X

(IPF) Excluded Distinct Part Units Care for Excluded Allows acute care hospitals with excluded distinct part inpatient Inpatient rehabilitation units to relocate inpatients from the excluded distinct Rehabilitation Unit Patients in the Acute

part rehabilitation unit to an acute care bed and unit as a result of this PHE. X

Care Unit of a Hospital


13 10/2020

Waiver/Flexibility Summary CR DR Supporting Care CMS has determined it is appropriate to issue a blanket waiver for Patients in Long to long-term care hospitals (LTCHs) where an LTCH admits or Term Care Acute discharges patients in order to meet the demands of the emergency Hospitals (LTCHs) from the 25-day average length of stay requirement at § 412.23(e)

(2), which allows these hospitals to participate in the LTCH PPS. In addition, during the applicable waiver time period, CMS has determined it is appropriate to issue a blanket waiver to hospitals not yet classified as LTCHs, but seeking classification as an LTCH, to exclude patient stays where the hospital admits or discharges patients in order to meet the demands of the emergency from the 25-day average length of stay requirement, which must be met in order for these hospitals to be eligible to participate in the LTCH PPS.

X

Care for Patients in Allows extended neoplastic disease care hospitals to exclude Extended Neoplastic inpatient stays where the hospital admits or discharges patients Disease Care in order to meet the demands of the emergency from the greater Hospital than 20-day average length of stay requirement, which allows these

facilities to be excluded from the hospital inpatient prospective payment system and paid an adjusted payment for Medicare inpatient operating and capital-related costs under the reasonable cost-based reimbursement rules.

X

Skilled Nursing Using the authority under Section 1812(f) of the Act, CMS is Facilities (SNFs) waiving the requirement for a 3-day prior hospitalization for

coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

X


14 10/2020

Waiver/Flexibility Summary CR DR Durable Medical When DMEPOS is lost, destroyed, irreparably damaged, Equipment, or otherwise rendered unusable, allow the DME Medicare Prosthetics, Administrative Contractors (MACs) to have the flexibility to waive Orthotics, and replacements requirements such that the face-to-face requirement, Supplies (DMEPOS) a new physician’s order, and new medical necessity documentation

are not required. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable as a result of the emergency.

X

Modification of Modifies the 60-day limit to allow a physician or physical therapist 60-Day Limit for to use the same substitute for the entire time he or she is unavailable Substitute Billing to provide services during the COVID-19 emergency, plus an Arrangements additional period of no more than 60 continuous days after the (Locum Tenens) public health emergency expires. On the 61st day after the public

health emergency ends (or earlier if desired), the regular physician or physical therapist must use a different substitute or return to work in his or her practice for at least one day in order to reset the 60-day clock. Physicians and eligible physical therapists must continue to use the Q5 or Q6 modifier (as applicable) and do not need to begin including the CR modifier until the 61st continuous day.

X

Critical Access Hospitals

Waives the requirements that Critical Access Hospitals limit the number of inpatient beds to 25, and that the length of stay, on an average annual basis, be limited to 96 hours.

X

Replacement Medicare payment may be permitted for replacement prescription Prescription Fills fills (for a quantity up to the amount originally dispensed) of

covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable by damage due to the disaster or emergency.

X

Hospitals Classified as Sole Community Hospitals (SCHs)

Waives certain eligibility requirements for hospitals classified as SCHs prior to the PHE, specifically the distance requirements and the “market share” and bed requirements (as applicable).

X

Hospitals Classified For hospitals classified as MDHs prior to the PHE, waives the as Medicare- eligibility requirements that the hospital has 100 or fewer beds Dependent, Small Rural Hospitals

during the cost reporting period and that at least 60 percent of the hospital’s inpatient days or discharges were attributable to X

(MDHs) individuals entitled to Medicare Part A benefits during the specified hospital cost reporting periods.


15 10/2020

Waiver/Flexibility Summary CR DR IRF 60 Percent Rule Allows an IRF to exclude patients from its inpatient population for

purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency. In addition, during the applicable waiver time period, we would also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF.

X

Waivers of certain Allows a hospital or Community Mental Health Center (CMHC) hospital and to consider temporary expansion locations, including the patient’s Community Mental home, to be a provider-based department of the hospital or Health Center extension of the CMHC, which allows institutional billing for (CMHC) Conditions of Participation and

certain outpatient services furnished in such temporary expansion locations. If the entire claim falls under the waiver, the provider X X

provider-based rules would only use the DR condition code. If some claim lines fall under this waiver and others do not, then the provider would only append the CR modifier to the particular line(s) that falls under the waiver.

Billing Procedures for ESRD services when the patient is in a SNF/NF

In an effort to keep patients in their SNF/NF and decrease their risk of being exposed to COVID-19, ESRD facilities may temporarily furnish renal dialysis services to ESRD beneficiaries in the SNF/NF instead of the offsite ESRD facility. The in-center dialysis center should bill Medicare using Condition Code 71 (Full care unit. Billing for a patient who received staff-assisted dialysis services in a hospital or renal dialysis facility). The in-center dialysis center should also apply condition code DR to claims if all the treatments billed on the claim meet this condition or modifier CR on the line level to identify individual treatments meeting this condition.

X X

Clinical Indications for Certain Respiratory, Home Anticoagulation Management, Infusion Pump and Therapeutic Continuous Glucose Monitor national and local coverage determinations

In the interim final rule with comment period (CMS-1744-IFC and CMS-5531-IFC) CMS states that clinical indications of certain national and local coverage determinations will not be enforced during the COVID-19 public health emergency. CMS will not enforce clinical indications for respiratory, oxygen, infusion pump and continuous glucose monitor national coverage determinations and local coverage determinations

X


16 10/2020

Waiver/Flexibility Summary CR DR Face-to-face In the interim final rule with comment period (CMS-1744-and In-person IFC) CMS states that to the extent a national or local coverage Requirements for national and

determination would otherwise require a face-to-face or in-person encounter for evaluations, assessments, certifications or other X

local coverage implied face-to-face services, those requirements would not apply determinations during the COVID-19 public health emergency. Requirement for DMEPOS Prior Authorization

The requirement to submit a prior authorization request for certain DMEPOS items and services was paused. Suppliers were given the option to voluntary continue submitting prior authorization requests or to skip prior authorization and have the claim reviewed through post payment review at a later date. Claims that would normally require prior authorization, but were submitted without going through the process should be submitted with a CR modifi er.

X

Signature requirements for proof of delivery

The signature requirement for Part B drugs and certain Durable Medical Equipment (DME) that require a proof of delivery and/ or a beneficiary signature was waived. Providers should use a CR modifier on the claim and document in the medical record the appropriate delivery date and that a signature could not be obtained because of COVID-19.

X

Part B Prescription Drug Refills

MACs may exercise flexibilities regarding the payment of Medicare Part B claims for drug quantities that exceed usual supply limits, and to permit payment for larger quantities of drugs, if necessary. MACs may require the use of the CR modifier in these cases.

X

Services provided by the hospital in the patient’s home as a provider-based outpatient department when the patient is registered as a hospital outpatient.

During the COVID-19 PHE, hospitals may furnish clinical staff services in the patient’s home as a provider-based outpatient department and bill and be paid for these services as Hospital Outpatient Department (HOPD) services when the patient is registered as a hospital outpatient. Hospitals should bill as if the services were furnished in the hospital, including appending the PO modifier for excepted items and services and the PN modifier for non-excepted services. The DR condition code should also be appended to these claims.

X

Medicare FFS Questions & Answers (FAQs) available on the Waivers and Flexibilities webpage apply to items and services for Medicare beneficiaries in the current emergency. These FAQs are displayed in these files: • COVID-19 FAQs (https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf) • FAQs that apply without any Section 1135

(https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_ Medicare_FFS_Emergency_QsAs.pdf) or other formal waiver.


17 10/2020

https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf

• FAQs apply only with a Section 1135 (https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf) waiver or, when applicable, a Section 1812(f) waiver.

Blanket Waivers Issued by CMS View the complete list (https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf) of COVID-19 blanket waivers.

Counseling and COVID-19 Testing To prevent further spread of COVID-19, a key strategy includes quarantine and isolation while patients wait for test results or after they get positive test results – regardless of showing symptoms.

Physicians and other health care practitioners who counsel patients during their medical visits have an opportunity to decrease the time between patient-testing and quarantine/isolation, especially when this counseling happens concurrent with COVID-19 testing. Working in partnership with public health personnel, providers could speed the counseling, testing, and referrals for case tracing initiation to reduce potential exposures and additional cases of COVID-19. By having patients isolated 1-2 days earlier, spread of COVID-19 can be reduced significantly. Modeling shows early isolation can reduce transmission by up to 86 percent.

Through counseling, providers can discuss with patients: 1. The signs and symptoms of COVID-19. 2. The immediate need to separate from others by isolation or quarantine, particularly while awaiting test

results. 3. The importance of informing close contacts of the person being tested (e.g., family members) to separate

from the patient awaiting test results. 4. If the patient tests positive, the patient will be contacted by the public health department to learn

the names of the patient’s close contacts. The patient should be encouraged to speak with the health department

5. The services that may be available to assist the patient in successfully isolating or quarantining at home.

This early intervention of counseling steps and isolation can reduce spread of COVID-19.

How to Bill for Counseling Services These counseling services are covered by Medicare. Physicians and other practitioners furnishing counseling services to people with Original Medicare should use existing and applicable coding and payment policies to report services, including evaluation and management visits (https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf).

When furnishing these services during 2020, when physicians and other practitioners spending more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) providing counseling or coordination of care, use time to select the level of visit reported.


18 10/2020

https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdfhttps://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdfhttps://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdfhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdfhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdfhttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

Please review the following provider resources: Provider Counseling Q&A: https://www.cms.gov/files/document/covid-provider-counseling-qa.pdf

Provider Counseling Talking Points: https://www.cms.gov/files/document/covid-provider-patient-counseling-talking-points.pdf

Provider Counseling Check List: https://www.cms.gov/files/document/covid-provider-patient-counseling-checklist.pdf

Handout for Patients to Take Home: https://www.cdc.gov/coronavirus/2019- ncov/downloads/php/318271-A_FS_ KeyStepsWhenWaitingForCOVID-19Results_3.pdf

Please also review the following information from the Centers for Disease Control and Prevention: Overall: https://www.cdc.gov/coronavirus/2019-nCoV/index.html

Testing: https://www.cdc.gov/coronavirus/2019-ncov/testing/index.html

Symptoms: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

Self Care: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/index.html

Care at Home: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for-someone.html

Contact Tracing: https://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.html

https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/principles-contact-tracing-booklet.pdf

https://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdf

Billing for Professional Telehealth Distant Site Services During the Public Health Emergency CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

View a complete list of services (https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes) payable under the Medicare Physician Fee Schedule when furnished via telehealth.


19 10/2020

https://www.cms.gov/fihttps://www.cms.gov/fihttps://www.cms.gov/fihttps://www.cdc.gov/coronavirus/2019-ncov/downloads/php/318271-A_FS_https://www.cdc.gov/coronavirus/2019-nCoV/index.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/testing/index.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/index.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for-someone.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/php/open-america/contact-tracing.htmlhttps://www.cdc.gov/coronavirus/2019-ncov/downloads/php/principles-contact-tracing-booklet.pdfhttps://www.cdc.gov/coronavirus/2019-ncov/downloads/case-investigation-contact-tracing.pdfhttps://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

When billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the PHE, bill with: • Place of Service (POS) equal to what it would have been had the service been furnished in-person • Modifier 95, indicating that the service rendered was actually performed via telehealth

As a reminder, CMS is not requiring the CR modifier on telehealth services. However, consistent with current rules for telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims: • Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous

(store and forward) technology, use GQ modifier • Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.

CMS released a video providing answers to common questions about the Medicare telehealth services benefit.

Video (https://www.youtube.com/watch?v=Bsp5tIFnYHk)

Teaching Physicians and Residents: Expansion of CPT Codes that May Be Billed with the GE Modifi er Teaching physicians and residents: Expansion of CPT codes that may be billed with the GE modifier under 42 CFR 415.174 on and after March 1, 2020, for the duration of the public health emergency: • Residents furnishing services at primary care centers may provide an expanded set of services to beneficiaries,

including levels 4-5 of an office/outpatient Evaluation and Management (E/M) visit, telephone E/M, care management, and some communication technology-based services

• This expanded set of services are CPT codes 99204-99205, 99214-99215, 99495-99496, 99421-99423, 99452, and 99441-99443 and HCPCS codes G2010 and G2012

• Teaching physicians may submit claims for these services furnished by residents in the absence of a teaching physician using the GE modifier

Medicare Administrative Contractors will automatically reprocess claims billed with the GE modifier on or after March 1, 2020, that were denied. You do not need to do anything.

Families First Coronavirus Response Act Waives Coinsurance and Deductibles forAdditional COVID-19 Related Services The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients who receive COVID-19 testing-related services. These services are medical visits under the HCPCS evaluation and management categories described below when outpatient providers, physicians, or other providers and suppliers who bill Medicare for Part B services order or administer COVID-19 lab tests regardless of the HCPCS codes they use to report the tests.

Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the PHE; that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes


20 10/2020

https://www.youtube.com/watch?v=Bsp5tIFnYHk

of determining the need for such a test; and are in any of 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

Cost-sharing does not apply to the above medical visit services for which payment is made to: • 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)

Previously, CMS made available the CS modifier for the gulf oil spill in 2010; however, CMS recently repurposed the CS modifier for COVID-19 purposes. Now, for services furnished on March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.

The HCPCS codes physicians and non-physician practitioners should use for billing services are available at https://www.cms.gov/files/zip/cs-modifier-hcpcs-codes-physicians-non-physician-practitioners.zip. For services Medicare pays under the Outpatient Prospective Payment System (OPPS), use the codes available at https://www.cms.gov/files/document/cs-waiver-opps-codes.pdf. RHCs and FQHCs must use the codes at https://www.cms.gov/files/zip/cs-codes-rhc-fqhc.zip. CAHs should use the OPPS list, except Method II CAHs may use either the OPPS list or the physician and non-physician practitioner list, as appropriate.

COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers During the COVID-19 PHE, Medicare will cover a medically necessary emergency and non-emergency ground ambulance transportation from any point of origin to a destination that is equipped to treat the condition of the patient consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished. On an interim basis, we are expanding the list of destinations that may include but are not limited to: • Any location that is an alternative site determined to be part of a hospital, Critical Access Hospital (CAH),

or Skilled Nursing Facility (SNF) • Community mental health centers • Federally Qualified Health Centers (FQHCs) • Rural health clinics (RHCs) • Physicians’ offices • Urgent care facilities • Ambulatory Surgery Centers (ASCs)


21 10/2020

https://www.cms.gov/fihttps://www.cms.gov/fihttps://www.cms.gov/fi

• Any location furnishing dialysis services outside of an End-Stage Renal Disease (ESRD) facility when an ESRD facility is not available

• Beneficiary’s home

CMS expanded the descriptions for these origin and destination claim modifiers to account for the new covered locations: • Modifier D - Community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC

or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD facility • Modifier E – Residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the

beneficiary’s home • Modifier H - Alternative care site for hospital, including CAH, provider-based ASC, or freestanding

emergency center • Modifier N - Alternative care site for SNF • Modifier P - Physician’s office • Modifier R - Beneficiary’s home

For the complete list of ambulance origin and destination claim modifiers see Medicare Claims Processing Manual Chapter 15 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c15.pdf), Section 30 A.

New Specimen Collection Codes for Laboratories Billing for COVID-19 Testing To identify and reimburse specimen collection for COVID-19 testing, CMS established two Level II HCPCS codes, effective with line item date of service on or after March 1, 2020: • G2023 – Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]), any specimen source • G2024 – Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

(Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source

Note that G2024 is applicable to patients in a non-covered stay in a SNF and not to those residents in Medicare-covered stays (whose bundled lab tests would be covered instead under Part A’s SNF benefit at Section 1861(h) of the Act).

These codes are billable by clinical diagnostic laboratories.

Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients CMS instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that give recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID like in an outbreak. Starting on July 6, 2020, and for the duration of the public health emergency, consistent with sections listed in the CDC guidelines titled, “Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel,” original Medicare and Medicare Advantage plans cover diagnostic COVID-19 lab tests:


22 10/2020

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c15.pdf

Diagnostic Testing • Testing residents with signs or symptoms of COVID-19 • Testing asymptomatic residents with known or suspected exposure to an individual infected with SARS-

CoV-2, including close and expanded contacts (e.g., there is an outbreak in the facility) • Initial (baseline) testing of asymptomatic residents without known or suspected exposure to an individual

infected with SARS-CoV-2 is part of the recommended reopening process • Testing to determine resolution of infection

Original Medicare and Medicare Advantage Plans don’t cover non-diagnostic tests.

Skilled Nursing Facility (SNF) Benefit Period Waiver - Provider Information CMS recognizes that disruptions arising from a PHE can affect coverage under the SNF benefit: • Prevent a beneficiary from having the 3-day inpatient qualifying hospital stay (QHS) • Disrupt the process of ending the beneficiary’s current benefit period and renewing their benefits.

Emergency waivers of QHS and benefit period requirements under §1812(f) of the Social Security Act help restore SNF coverage that beneficiaries affected by the emergency would be entitled to under normal circumstances.

Using the authority under section 1812(f) of the Social Security Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a QHS, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who recently exhausted their SNF benefits, the waiver authorizes a one-time renewal of benefits for an additional 100 days of Part A SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

For the QHS waiver: • All beneficiaries qualify, regardless of whether they have SNF benefit days remaining • The beneficiary’s status of being “affected by the emergency” exists nationwide under the current PHE.

(You do not need to verify individual cases.)

In contrast, for the Benefit Period Waiver: • Beneficiaries who exhaust their SNF benefits can receive a renewal of SNF benefits under the waiver except

in one particular scenario: that is, those beneficiaries who are receiving ongoing skilled care in a SNF that is unrelated to the emergency, as discussed below. To qualify for the benefit period waiver, a beneficiary’s continued receipt of skilled care in the SNF must in some way be related to the PHE. One example would be when a beneficiary who had been receiving daily skilled therapy, then develops COVID-19 and requires a respirator and a feeding tube. We would also note that beneficiaries who do not themselves have a COVID-19 diagnosis may nevertheless be affected by the PHE; for example, when disruptions from the PHE cause delays in obtaining treatment for another condition.

• Would not apply to those beneficiaries who are receiving ongoing skilled care in the SNF that is unrelated to the emergency - a scenario that would have the effect of prolonging the current benefit period and precluding a benefit period renewal even under normal circumstances. For example, if the patient has a


23 10/2020

continued skilled care need (such as a feeding tube) that is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits under the section 1812(f) waiver as it is this continued skilled care in the SNF rather than the emergency that is preventing the beneficiary from beginning the 60 day “wellness period.”

• In making such determinations, a SNF resident’s ongoing skilled care is considered to be emergency-related unless it is altogether unaffected by the COVID-19 emergency itself (that is, the beneficiary is receiving the very same course of treatment as if the emergency had never occurred). This determination basically involves comparing the course of treatment that the beneficiary has actually received to what would have been furnished absent the emergency. Unless the two are exactly the same, the provider would determine that the treatment has been affected by – and, therefore, is related to – the emergency.

• Providers should use the above criteria in determining when to document on the claim that the patient meets the requirement for the waiver.

In this situation, we would also ask those providers to work with their respective MACs to provide any documentation needed to establish that the COVID-19 emergency applies for the benefit period waiver under §1812(f) for each benefit period waiver claim. Additionally, we also recognize that during the COVID-19 PHE, some SNF providers may have not yet submitted the PPS assessments for the benefit period waiver. In these limited circumstances, providers may utilize the Health Insurance Prospective Payment System (HIPPS) code that was being billed when the beneficiary reached the end of their SNF benefit period.

Billing Instructions The following guidance provides specific instructions for using the QHS and benefit period waivers, as well as how this affects claims processing and SNF patient assessments.

To bill for the QHS waiver, include the DR condition code.

To bill for the benefit period waiver: • Submit a final discharge claim on day 101 with patient status 01, discharge to home • Readmit the beneficiary to start the benefit period waiver.

For admission under the benefit period waiver: • Complete a 5-day PPS Assessment. (The interrupted stay policy does not apply.) • Follow all SNF Patient Driven Payment Model (PDPM) assessment rules. • Include the HIPPS code derived from the new 5-day assessment on the claim. • The variable per diem schedule begins from Day 1.

For SNF benefit period waiver claims, include the following: • Condition code DR - identifies the claims as related to the PHE • Condition code 57 (readmission) - this will bypass edits related to the 3-day stay being within 30 days • COVID100 in the remarks - this identifies the claim as a benefit period waiver request.

If you previously submitted a claim for a benefit period waiver that rejected for exhausted benefits, take either of the following actions: 1. If you billed the discharge and readmission correctly:

• Cancel the rejected claim to remove it from claims history. DO NOT submit an adjustment to the rejected claim.


24 10/2020

• Once the cancel has finalized, resubmit the initial claim. • If you submit a claim without COVID100 in the remarks, we cannot process it for an additional 100

benefit days. 2. If you did not previously bill for a discharge on the last covered day to start a new admission with the

benefit period waiver days: • Cancel the paid claim that includes the last covered coinsurance benefit day. • Once the cancel is processed, resubmit as a final bill with patient status equal to 01. • Cancel the initial benefit period waiver claim that rejected for exhausted benefits. You can submit this

concurrently with the cancel of the paid claim. • Once the rejected claim is cancelled, submit an initial bill for the benefit period waiver following the

same instructions as #1 above.

Please note, as previously stated, ongoing skilled care in the SNF that is unrelated to the PHE does not qualify for the benefit period waiver. You must determine if the waiver applies in accordance with the criteria set forth above. If so: • Fully document in medical records that care meets the waiver requirements; this may be subject to post

payment review. • Track benefit days used in the benefit period waiver spell and only submit claims with covered days 101 - 200. • Once the additional 100 days have been exhausted, follow existing processes to continue to bill Medicare

no-pay claims until you discharge the beneficiary. • Identify no-pay claims as relating to the benefit period waiver by using condition code DR and including

“BENEFITS EXHAUST” in the remarks field.

MACs must manually process claims to pay the benefit period waiver but will make every effort to ensure timely payment. Please allow sufficient time before inquiring about claims in process.

Note: You must abide by all other SNF billing guidelines.

Beneficiary Notice Delivery Guidance in Light of COVID-19 If you are treating a patient with suspected or confirmed COVID-19, CMS encourages the provider community to be diligent and safe while issuing the following beneficiary notices to beneficiaries receiving institutional care: • Important Message from Medicare (IM)_CMS-10065 • Detailed Notices of Discharge (DND)_CMS-10066 • Notice of Medicare Non-Coverage (NOMNC)_CMS-10123 • Detailed Explanation of Non-Coverage (DENC)_CMS-10124 • Medicare Outpatient Observation Notice (MOON)_CMS-10611 • Advance Beneficiary Notice of Non-Coverage (ABN)_CMS-R-131 • Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN)_CMS-10055 • Hospital Issued Notices of Non-Coverage (HINN)

In light of concerns related to COVID-19, current notice delivery instructions provide flexibilities for delivering notices to beneficiaries in isolation. These procedures include: • Hard copies of notices may be dropped off with a beneficiary by any hospital worker able to enter a room

safely. A contact phone number should be provided for a beneficiary to ask questions about the notice, if the individual delivering the notice is unable to do so. If a hard copy of the notice cannot be dropped off ,


25 10/2020

notices to beneficiaries may also be delivered via email, if a beneficiary has access in the isolation room. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice, and when and to where the email was sent.

• Notice delivery may be made via telephone or secure email to beneficiary representatives who are offsite. The notices should be annotated with the circumstances of the delivery, including the person delivering the notice via telephone, and the time of the call, or when and to where the email was sent.

We encourage the provider community to review all of the specifics of notice delivery, as set forth in Chapter 30 of the Medicare Claims Processing Manual at https://www.cms.gov/media/137111.

Additional Information The complete list of COVID-19 blanket waivers is available at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf.

Review information on the current emergencies webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.

If you have questions, your MACs may have more information. Find their website at http://go.cms.gov/MAC-website-list.

Providers may also want to view the Survey and Certification Frequently Asked Questions at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html.

Document History Date of Change August 26, 2020

August 20, 2020

July 30, 2020

Description We revised the article to add information about the HCPCS codes for OPPS, RHC, FQHC, and CAH billers in the Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services section. All other information remains the same. We revised the article to add information about the HCPCS codes in the Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services section. All other information remains the same. We revised the article to add the section, “Counseling and COVID-19 Testing.” All other information remains the same.


26 10/2020

https://www.cms.gov/media/137111https://www.cms.gov/fihttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-pagehttps://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-pagehttp://go.cms.gov/MAC-website-listhttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certifi

Date of Change July 24, 2020

July 17, 2020

July 8, 2020

July 1, 2020

June 26, 2020

June 19, 2020

June 1, 2020

April 10, 2020

Description We revised the article to add clarifying language to the Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services section to show it applies to lab tests regardless of the HCPCS codes used to report those tests. All other information remains the same. We revised the article to: - Update information on CDC nursing home patients/residents testing - Add clarifying language to the Skilled Nursing Facility (SNF) Benefit Period Waiver - Provider Information section

All other information remains the same. We revised the article to add a row at the end of the Waiver/Flexibility table (page 7) to address services provided by the hospital in the patient’s home as a provider-based outpatient department when the patient is registered as a hospital outpatient. Also, we added the section on Teaching Physicians and Residents: Expansion of CPT Codes that May Be Billed with the GE Modifi er. All other information remains the same. We revised the billing instructions on page 12 of this article. Changes include instructions to readmit the beneficiary on day 101 to start the Skilled Nursing Facility (SNF) benefit period waiver. All other information remains the same. We revised the article to add the section, “Skilled Nursing Facility (SNF) Benefit Period Waiver - Provider Information” and related billing instructions. All other information remains the same. We revised the article to add the section, “Medicare Coverage of COVID-19 Testing for Nursing Home Residents and Patients.” All other information remains the same. We revised the article to add a section on Clarification for Using the “CR” Modifier and “DR” Condition Code. All other information remains the same. Note: We revised this article to: • Link to all the blanket waivers related to COVID-19 • Provide place of service coding guidance for telehealth claims • Link to the Telehealth Video for COVID-19 • Add information on the waiver of coinsurance and deductibles for certain

testing and related services • Add information on the expanded use of ambulance origin/destination

modifiers • Provide new specimen collection codes for clinical diagnostic laboratories

billing • Add guidance regarding delivering notices to beneficiaries.

All other information is the same.


27 10/2020

Date of Change March 20, 2020

March 19, 2020

March 18, 2020

March 16, 2020

Description We revised the article to add a note in the Telehealth section to cover the use of modifiers on telehealth claims and to explain the DR condition code is not needed on telehealth claims under the waiver. All other information is the same. We corrected a typo in the article. One of the e-visit codes was incorrectly stated as 99431 and we corrected it to show 99421. We revised this article to include information about the Telehealth waiver. All other information remains the same. Initial article released.


28 10/2020

Claim Status Category and Claim Status Codes Updates MLN Matters Number: MM11796 Related CR Release Date: August 28, 2020 Related CR Transmittal Number: R10322CP Related Change Request (CR) Number: 11796 Effective Date: January 1, 2021 Implementation Date: January 4, 2021

Provider Types Affected This MLN Matters Article is for physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Provider Action Needed This article informs you of updates to the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgement transactions. Please make sure your billing staffs are aware of these updates.

Background The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards adopted under HIPAA for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s). Proprietary codes may not be used in the ASC X12 276/277 transactions to report claim status.

The National Code Maintenance Committee (NCMC) meets at the beginning of each ASC X12 trimester meeting (January/February; June; and September/October) and makes decisions about additions, modifications, and retirement of existing codes. The NCMC has decided to allow the industry 6 months for implementation of newly added or changed codes.

The code sets are available at https://nex12.org/index.php/codes/17-health-care-claim-status-category and https://nex12.org/index.php/codes/16-health-care-claim-status. Included in the code lists are specific details, including the date when a code was added, changed, or deleted.

All code changes approved during the September/October 2020 NCMC meeting will be posted on these two websites on or about November 1, 2020.

The Centers for Medicare & Medicaid Services (CMS) will issue notifications regarding the need for future updates to these codes. When instructed, Medicare contractors must update their claims systems to ensure that the current version of each of these codes is used in their claims status responses. Medicare and shared system changes will be made as necessary as part of a routine release to reflect applicable changes such as retirement of previously used codes or newly created codes.

Continued >> CPT codes, descriptors and other data only are copyright 2019 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply

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