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Copyright © 2020 HomeTown Health, LLC. All rights reserved. 1
4/21/2020
Billing and Reimbursement
COVID-19 PHE
Paid Correctly!
Agenda
Billing and Reimbursement
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4/21/2020
Reopening America’s Healthcare
Surgeries and
procedures,
chronic care, and
ultimately
preventative care
Need adequate
workforce, testing
and supplies in
case of a surge
Evaluate necessity
of care. Prioritize
surgeries and
complex care
needed
PPE should be
worn by staff and
patients without
jeopardizing your
supply in case of
surge.
Maximum use of
telehealth is
encouraged
In coordination
with state and
local public health,
evaluate trends
Consider non-
COVID treatment
zones with staff
and patient
screening.
Staff should be
tested and
quarantined if
symptomatic.
CMS recognizes
that hospitals may
not be in a surge
area and need to
reopen
Reopening America’s Healthcare
Staffing levels
must remain
adequate in case
of surge
Low patient
volumes, minimize
wait times, waiting
room chairs 6 ft
apart
Use thorough
cleaning and
sanitizing in all
areas
When able testing
should be used on
staff and patients
for screening
In person non-
emergent care
should be
performed away
from COVID care
Visitors prohibited
when possible and
screened if
necessary
Equipment
especially
ventilators should
be fully disinfected
after use
Continually
evaluate to make
sure you are in a
low COVID zone
Staff should not
work across both
zones
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4/21/2020
Let’s Do This!
Information Overload!
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4/21/2020
Don’t Panic!
We will discuss how to handle all of this information
Telehealth
Medicare Telehealth Codes
https://www.cms.gov/files/document/se20016.pdf
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4/21/2020
Who can provide Telehealth?
• Physicians
• Nurse practitioners (NPs)
• Physician assistants (PAs)
• Nurse-midwives
• Clinical nurse specialists (CNSs)
• Certified registered nurse anesthetists
• Clinical psychologists (CPs) and clinical social workers (CSWs) CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for CPT codes 90792, 90833, 90836, and 90838.
• Registered dietitians or nutrition professional *Services must be within a provider’s scope of practice and consistent with Medicare benefit rules that apply to all services
• Per Palmetto GBA 4/17/2020
Do Not Use/Use For Telehealth
THE CR MODIFIER IS NOT REQUIRED
THE GT MODIFIER IS NOT USED FOR PART B
ONLY FOR METHOD II CAHS
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4/21/2020
Use For Telehealth
THE DR CONDITION CODE MAY BE
USED AS TELEHEALTH IS A WAIVER UNDER 1135
USE MODIFIER CS FOR ALL COST
SHARE WAIVED SERVICES
https://www.youtube.com/watch?v=bdb9NKtybzo&feature=youtu.be
RHC Telehealth
• Guidance released Friday 4/17/2020
• Distant site telehealth services can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice. Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the RHC or FQHC, and can furnish any telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS)
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4/21/2020
RHC Guidance 4/17/20
• From January 27, 2020 to June 30, 2020
• Bill the telehealth as if it were a regular face to face visit using modifier 95.
• The telehealth visit will pay at $92
• The new rate will be paid retroactively after July 1st.
• After July 1st, the RHC will bill telehealth using the code G2025 to be paid at $92
• This extends as long as there is a PHE in effect
• Wrap around payments do not apply to these services
Important Information
Example:
Medicare RHC visit (AIR) -$160
Medicare telehealth$92
Recoupment -$68
If your current RHC AIR rate is > $92 when claims are reprocessed after July 1, 2020 that amount will
be recouped from Medicare payments.
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4/21/2020
Virtual Check-ins - RHC
Communication, multiple methods, not video, Can be telephone, text message, email or patient portal
This is not telemedicine
Bill G0071 Do NOT use modifier 95!
Payment will be $24.76
Poll Question
Are your RHCs billing for telehealth?
• Yes
• No
• Not sure
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4/21/2020
Accelerated Advance Payments - RHC
Qualified RHCs
• Request payment
from your MAC
• Recoupment will
begin at `120 days
Different Types of Visits
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4/21/2020
Q: Has CMS given more guidance on telehealth for specialty nurses such as Wound Care, diabetic education etc.?
A: 97802-97804 for Medical Nutrition Therapy are on the approved list of telehealth codes. G0108 for Diabetic Mgmtis also on the list. Face to face services such as wound care are not.
Q:How do we bill them?
A: No definitive guidance but if they do not normally bill on a 1500 then bill on the UB.
Q: Can a hospital bill the Q3014?
A: If a beneficiary is at the hospital and receives telehealth services, the hospital can bill the Q3014
Medicaid Updates
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4/21/2020
Iowa Medicaid Updates
• 4/16/2020 Iowa DCH is NOT waiving Prior Authorizations but is extending prior auths for elective services obtained prior to the emergency in 90-day increments until emergency is over.
• Effective 4/1/20 they are extending claims filing deadlines to 270 days from DOS.
• Telehealth Originating sites are where the patient is located and should bill Q3014 if in your facility (exception RHCs)
• Telehealth Distant sites are where the physician is located and should bill applicable CPT code and POS 02 with modifier 95.
• Drive Through testing sites should bill using POS 15 on the 1500 or hospitals should bill using Bill Type 141
Amerigroup Iowa
• Inpatient and respiratory care
• PA requirements are suspended for patient transfers: all hospital inpatient transfers to lower levels of care (by land only). Although PA is not required, Amerigroup requests voluntary notification via the usual channels to aid in our members’ care coordination and management.
• The 21-day inpatient requirement before transferring a patient to a long-term acute care hospital is suspended.
• Concurrent review for discharge planning will continue unless required to change by federal or state directive.
• PA requirements are suspended for COVD-19 DME, including oxygen supplies, respiratory devices and continuous positive airway pressure (CPAP) devices for patients diagnosed with COVID-19, along with the requirement for authorization to exceed quantity limits on gloves and masks.
• Respiratory services for acute treatment of COVID-19 will be covered. PA requirements are suspended where previously required.
• No information on Iowa Total Care
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4/21/2020
Georgia Medicaid GAMMIS
• Nursing Home Guidance 4/20/20
• Waiving Level I and Level II PASRR screenings
• Receiving facility has 30 days to complete
• Waiving 3-day stay if patient is displaced because of COVID-19 emergency
• DCH is suspending PAs only for non-elective inpatient hospitalizations only.
• CMOs are following FFS guidelines in most cases
GA Medicaid Telehealth Billing
• Providers that were billing for telehealth prior to the PHE will continue to use the designated codes associated with the service rendered and the GT modifier.
• Codes recently approved for the PHE will need to use POS code 02.
• You can verify which CPT codes need modifiers by using the procedure code search tab.
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4/21/2020
Florida Medicaid Update
On Wednesday
Florida Webinar
Poll QuestionHave you seen a decrease in the volume of claims billed since the PHE was declared?
Yes, a big decrease
Yes, but not a big decrease
No, we are billing the same amount of claims
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4/21/2020
Poll Question
If you have seen a decrease in claims, what are you using the extra time for?
Working outstanding AR
Working denials
I’ve been furloughed or laid off
I’m just enjoying not being so busy
Other, put in Q and A pane
Commercial Updates
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4/21/2020
Anthem BCBS Updated 4/16
COVID-19 Tests and visits have cost-share waived through May 31st
Member cost-share waived for telehealth visits including mental health and substance use disorders
In-network providers can waive cost-sharing for telephonic only care
Cost-sharing waived for a visit to be tested, even if test not done beginning 3/18/20
Cost sharing includes co-pays, Co-insurance & deductibles
Anthem Reimbursement Methods
Inpatient and ER visits
• Contracted rates inclusive of co-pays and deductibles if visit is inclusive of COVID-19 testing or treatment
Drive-Through Labs – 87635 and U0002
• Fee schedule & cost sharing amounts
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4/21/2020
Anthem Codes to Use
Effective 3/17 for therapy telehealth:
Physical therapy (PT) evaluation codes 97161, 97162, 97163, and 97164
Occupational (OT) therapy evaluation codes 97165, 97166, 97167, and 97168
PT/OT treatment codes 97110, 97112, 97530, and 97535
Speech therapy (ST) evaluation codes 92521, 92522, 92523, and 92524
ST treatment codes 92507, 92526, 92606, and 92609
For telephonic visits:
CPT codes 99441, 99442, 99443, 98966, 98967, 98968 and the place of service code that depicts where the provider’s telephonic-only services occurred.
For telehealth use POS 02 and modifier 95
Anthem Authorizations
Waived for patient transfers from Inpatient to SNF
21 day stay prior to transfer to LTCH suspended
Prior authorizations already obtained are extended to 90 days.
Concurrent reviews for discharge planning WILL continue.
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4/21/2020
Audits and Reviews
Hospital claims audits requiring additional clinical documentation will be limited for the next 90 days
Retrospective reviews will be suspended but reserve the right to go back later
Timely filing requirements remain in place!
Aetna GA & FL
• Authorization for hospital admissions is waived for commercial and Medicare Advantage plans.
• Notify Aetna of admission within 48 hours
• If you want to submit clinical information you can
• Effective for 30 days through May 6th
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4/21/2020
Aetna Iowa
• Waive member cost-sharing for inpatient admissions at all in-network facilities for treatment of COVID-19 or health complications associated with COVID-19. This policy applies to all Aetna-insured commercial plan sponsors and is effective immediately for any such admission through June 1, 2020.
• Waiving member cost-sharing for inpatient admissions at all in-network and out-of-network facilities for treatment of COVID-19 or health complications associated with COVID-19. This policy applies to all Aetna Individual and Group Medicare Advantage members and is effective March 25, 2020 for any such admission through June 1, 2020.
Aetna Telehealth
• Until June 4th, cost-sharing will be waived for telehealth for any diagnosis including virtual services and phone calls for commercial plans.
• Until further notice, zero-pay telemedicine visits for Individual & Group Medicare advantage plans for all diagnoses.
• Aetna reimburses all providers for telemedicine at the same rate as in-person visits.
• For telephone only codes (99441-99443, 98966-98968, G2010, G2012) there are reimbursement rates in the fee schedule that are not the same as E&M office visits 99201-99215. Given those telephone only codes do not equate to an office visit, they will not result in an office visit reimbursement rate.
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4/21/2020
Aetna Billing• For commercial members non-facility
telemedicine claims must use POS 02 with the 95 or GT modifier.
• Facilities should continue to use their respective POS; CPTs and the telemedicine modifiers must be noted on the UB-04 form as the Rev Code will not be sufficient.
• For Medicare members, POS 02 or POS 11, or the POS equal to what it would have been had the service been furnished in-person, along with the modifier 95 indicating that the service rendered was actually performed via telehealth, may be utilized and will reimburse at the same rate.
Aetna Authorizations
Initial pre-cert and prior authorization for admission to post-acute settings (SNF, IRF) waived for a commercial and Medicare plans all states
Post Acute locations to notify Aetna within 48 hrs and send records within 3 days
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4/21/2020
United Healthcare
• If a member receives treatment under a COVID-19 admission or diagnosis code between Feb. 4, 2020 and May 31, 2020, we will waive cost sharing (co-pays, coinsurance and deductibles) for the following:
• Office visits
• Urgent care visits
• Emergency department visits
• Observation stays
• Inpatient hospital episodes
• Acute inpatient rehab
• Long-term acute care
• Skilled nursing facilities
United Healthcare Authorizations
Until May 31, 2020
Discharges to SNF, Home Health, other PAC settings do not require prior Authorization
Receiving facility needs to notify within 24 hours
Inpatient admissions notify within 24 hrs or by 5 pm Monday for weekend admissions
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4/21/2020
United Healthcare Diagnostic Radiology
• Will not require prior authorizations for diagnostic radiology (diagnostic imaging) of the chest for COVID-19 patients during this national emergency.
• Urge providers to submit notification for CPT® codes 71250, 71260, 71270 for members with a COVID-19 diagnosis or suspected diagnosis, and who are enrolled in Medicaid and Individual and Group Market health plans.
• No notice is necessary for Medicare.
• Other chest CT scans continue to require prior authorization
United Healthcare Lab Billing
• UHC Does not recognize the distinction between CPT codes!!
• ONLY Use 87635 for ALL COVID-19 lab testing!
• Bill with the following ICD-10 Codes
• Suspected exposure to someone with Coronavirus use Z03.818
• Actual exposure to someone with Coronavirus use Z20.818
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4/21/2020
United Telehealth
• Effective from March 31, 2020 until June 18, 2020, they will waive cost sharing for in-network telehealth visits for medical, outpatient behavioral and physical, occupational and speech therapy services (PT/OT/ST)
• UnitedHealthcare is waiving the Centers for Medicare and Medicaid’s (CMS) originating site restriction and audio-video requirement for Medicare Advantage, Medicaid, and Individual and Group Market health plan members from March 18, 2020 until June 18, 2020. Eligible care providers can bill for telehealth services performed using interactive audio-video or audio-only, except in the cases where we have explicitly denoted the need for interactive audio/video, such as with PT/OT/ST, while a patient is at home.
Telehealth + Billing United
• Allowing all codes on the CMS Covered Telehealth list
• Scheduled telehealth visit with an established patient use 99211-99215 with POS 11, 20, 22, 23 and modifier 95
• E-visit through online portal – Use 99421-99423 with POS 11, 20, 22, 23, no modifiers required
• Virtual Check-in – Use G2012 with POS 11, 22, 20, 23, no modifiers required
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4/21/2020
United Healthcare Therapy Telehealth
• PT/OT/ST Codes that can be billed for telehealth through June 18, 2020
• Must be a live audio/visual visit
• No pre-recorded exercise videos
• No phone only visits
• There is no change to utilization management requirements for physical, occupational or speech therapy services. You should continue to comply with these requirements.
United Healthcare • Starting March 31, 2020 until June 18,
2020, UnitedHealth will also waive cost sharing for in-network, non-COVID-19 telehealth visits for its Medicare Advantage, Medicaid, and fully insured individual and group market health plans.
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4/21/2020
Humana Policy Changes
• Suspending pre and post-payment reviews
• Releasing claims under medical record review
• Reserve the right to do retro reviews
• Individual, Medicare Advantage, Medicaid & Commercial
• Sequestration is suspended until 12/31/2020
Humana
• Suspending nearly all pre-authorization requirements for participating/in-network providers. This applies to inpatient (acute and post-acute), outpatient, and all referrals for Humana’s individual and Group Medicare Advantage, Commercial Group, and Medicaid plans.
• Applies to both participating/in-network and non-participating /out-of-network providers when the member has a COVID-related diagnosis
• Non-par/out-of-network providers must continue to follow referral requirements and submit authorization requests per Humana’s policy
• Please continue to submit a notification as normal when your Humana-covered patients are admitted to the hospital, even when authorization is not required.
• Humana is extending previously approved authorizations to a 90-day approval timeframe, except for home health authorizations, which are being extended for 60 days.
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4/21/2020
Humana Lab CPT codes for billing
• For COVID-19 testing use U0001, U0002 and 87635
• Testing for other viral respiratory conditions to rule out COVID-19 use:
• CPT 87804 – Infectious agent antigen detection by immunoassay with direct optical observation; influenza
• CPT 87633 – Respiratory virus panel
• CPT 87486 – C. pneumoniae CPT 87581 – M. pneumonia
• The applicable ICD-10 code must also be on the claim
Cigna
Waiving cost-sharing for COVID-19 testing related visits until May 31stWaiving
Waiving prior authorizations for transfers of non-COVID-19 patients to LTAC to make room for COVID-19 surge patients
Waiving
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4/21/2020
Poll QuestionDo you currently have COVID-19 positive patients in your hospital?
Yes < 5 inpatients
Yes > 5 inpatients
No, we had some but no longer do
No, we haven’t had any COVID-19 patients
I have no idea
Coding Guidance
From CDC.gov
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ICD-10 Coding Guidance
• J12.89 – Other viral Pneumonia & B97.29 Other coronavirus as the cause of disease
Pneumonia Related to COVID-19
• J20.8 – Acute Bronchitis & B97.29
• NOS – J40 – Bronchitis & B97.29
Bronchitis Related to COVID-19
• J22 – Unsp. Lower Resp. Infection & B97.29
• NOS – J98.8 Resp. Disorder & B97.29
Acute Lower Respiratory Infection with COVID-19
• J80 – Acute Resp. Distress & B97.29
ARDS due to COVID-19
ICD-10 Coding Guidance
Exposure to COVID-19
• Ruled out use – Z03.818 – Encounter for observation of suspected exposure ruled out
• Actual exposure – Z20.828 – Contact with and suspected exposure to viral communicable disease
Signs & Symptoms no definitive Dx
• R05 – Cough
• R06.02 – Shortness of breath
• R50.9 – Fever
Not Appropriate for COVID-19
• B34.2 – Coronavirus unspecified
If documented Probable, possible, suspected COVID-19 do not code B97.29
• Assign a code for the symptoms instead
https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf
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4/21/2020
Modifier CS for Medicare
• Any service related to COVID-19 testing including telehealth will be covered.
• For services related to COVID-19 the co-insurance will be waived.
• Put the CS modifier on the service line and Medicare will pay 100% of the allowed amount.
• Do not collect from the patient.
• Telehealth claims will be reprocessed after July 1st if they were paid incorrectly.
• Refund any COVID-19 related money collected.
Example: Patient presents to ED & because of symptoms is tested for COVID-19.
Patient is also charged ED level, influenza A & B test, strep test, & urinalysis.
Patient is negative for COVID-19 & diagnosis is sinusitis. What lines do we append CS modifier?
All CPT code lines for payers who require them for cost-sharing waivers. Also coders need to code symptoms related to COVID-19
Also, does the CS modifier apply on inpatients?
No, CPT codes are not reported on inpatients so modifiers do not apply
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4/21/2020
Specimen Collection
•Specimen collection codes for COVID-19 testing
•G2023 and G2024
•Only for Independent Lab billing
New CPT codes for Antibodies
https://www.ama-assn.org/system/files/2020-04/cpt-assistant-guide-coronavirus-april-2020.pdf
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4/21/2020
Self-Pay Patients
How do we manage these patients?
• We cannot balance bill self pay patients
• Most hospitals do not send self-pay through the clearinghouse
• Check with your vendor to see if the claims can go through edits before going to your early out vendor.
• If a self-pay patient has any COVID related testing or treatment you cannot send them a statement for money owed.
• Edits should pick up any COVID CPT codes and/or ICD-10 codes
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4/21/2020
Edits for all patient
Hold claims with these
codes
All insurance
and self-pay
• ICD-10 codes
• J12.89
• J20.8
• J22
• J40
• J80
• J98.8
• R05
• R06.02
• R50.9
• B34.2
• B97.29
• Z03.818
• Z20.828
• U07.1
• CPT Codes
• U0001
• U0002
• 87635
• 71250
• 71260
• 71270
• 71035
When the claim hits an edit…
Check to see who the payer is or
if the patient is uninsured, and
the type of service.
Check the payer guidelines for
the type of service. Correct the
insurance claims
If the patient is uninsured and
the treatment or testing is
related to COVID-19 adjust the
account to zero.
01 02 03
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4/21/2020
COVID-19 Uninsured Claims
Run a report for all COVID-19 Lab charges or pull the COVID-19 Lab log
Review billing for all patients who have had a COID-19 test.
Check patient logs for prior visits where symptoms may not initially have resulted in a COVID-19 test. Minimum back to 3/1/20
Contact your early out vendor and pull back & close any COVID-19 self-pay accounts
If patients call the vendor have a contact person for them at the hospital business office who can help them.
COVID-19 Uninsured Claims
• Clinic visits
• Drive Through testing
• Telehealth patients
• Ambulance patients
Don’t forget your alternative sites
Create a new adjustment code for writing off uninsured COVID-19 patient accounts
It is important to track these for HHS payment tracking
Main purpose of funding is to allow you to write off these accounts
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4/21/2020
Real Life Example
• Patient comes to the ER on March 2, 2020 with complaint of a cough and is sent home with Rx.
• Patient returns to ER on March 3, 2020 via EMS with worsening cough and is again sent home.
• Patient returns the evening of March 3, 2020 and COVID-19 testing is done and the patient is admitted to inpatient with suspected COVID-19 virus.
• ALL 4 accounts are related to the COVID-19 testing and services.
• If the patient is uninsured, all charges will be written off.
• If the patient has insurance, cost sharing will be waived and specific billing rules will apply based on the payer.
Condition Code DR
• The DR modifier is to be used on all Medicare claims that are related to a COVID-19 waiver.
• Waivers include:
• SNF 3 day stay
• CAH hospital bed and hours
• PPS hospitals housing patients in other units
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4/21/2020
Questions?
Additional Resources
• https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fprovider%2Fdocs%2Fpublic%2Fresources%2Fnews%2F2020%2FTelehealth-Patient-Scenarios.pdf
• https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/
• https://www.ihaonline.org/Coronavirus_Billing_and_Financial_Resources
https://dhs.iowa.gov/ime/providers/faqs/covid19/telehealth
https://dhs.iowa.gov/sites/default/files/2115-MC-FFS_Billing_related_to_COVID-19.pdf?042020201507