SunStone is committed to assisting our clients navigate the ever-changing reimbursement and regulatory environment, keeping you ahead of the curve and ensuring appropriate reimbursement for services rendered during the public health emergency (“PHE”). In this second edition of the COVID-19 Q&A HotStone, we are providing some of the questions posed to us thus far, to include instances in which clarification was sought from CMS.
TELEHEALTH
Please clarify how a hospital provider-based clinic, such as a Pain Center, can capture the technical component of a telehealth service.
SunStone Response:
CMS, through its blanket 1135 waiver authority during the COVID-19 PHE, implemented Hospital without Walls, which allows the patient’s home to be considered an outpatient provider-based department (“PBD”) of the hospital if other applicable requirements (including non-waived conditions of participation) are met.
Accordingly, during the PHE, a hospital can bill the telehealth originating site fee (HCPCS Q3014) for telehealth services furnished by a practitioner from a hospital outpatient department if:
The patient is registered as an outpatient of the hospital;
The patient is located at home or other applicable temporary expansion location which has been made provider-based to the hospital;
The patient's home address is identified as a PBD location.
The telehealth originating site HCPCS Q3014 replaces G0463 for reporting the hospital outpatient clinic visit.
We understand new codes have been added to the telehealth list of services, including audio-only services. How should we appropriately report these services and where can we find a comprehensive list of Medicare telehealth services?
SunStone Response:
On April 30th, CMS issued a second Interim Final Rule (“IFC”), CMS-55341-IFC, which acknowledged the intensity of furnishing an audio-only visit during the PHE was not accurately captured by the valuation of these audio-only services as established in the March 31st COVID-19 IFC.
CMS further acknowledged that audio-only services are being furnished as a replacement for care that would otherwise be reported as an in-person or telehealth visit using the office/outpatient E/M codes. As such, based on the time requirements for the telephone codes and the times assumed for valuation of office/outpatient E&M codes, CMS is cross-walking payment for E&M levels 99212, 99213 and 99214 to 99441, 99442 and 99443 respectively and issued a separate waiver that Medicare telehealth services must be furnished using video technology. Further, these audio-only services have been added to the list of Medicare covered telehealth services for the duration of the PHE. CMS also clarified on its Office Hours call, to append modifier 95 to these newly covered audio-only services to identify these claims as telehealth.
The full list of Medicare telehealth services, including those recently added during the PHE, is available at:
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
Is the practitioner furnishing the telehealth service for a registered hospital outpatient required to be in the hospital when the patient is at home?
SunStone Response:
CMS clarified in their COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing that there are no payment restrictions on distant site practitioners furnishing Medicare telehealth services from their home during the PHE. The provider should however report the Place of Service (“POS”) code that would have been reported had the service been furnished in person ( in this case the facility), and append modifier 95 on the professional claim which will ensure the physician is reimbursed by Medicare at the same rate had they been furnished in person.
The facility would bill the telehealth originating site HCPCS Q3014 for the hospital outpatient clinic visit if the patient was registered as an outpatient, and the hospital applied for a temporary expansion location for the patient's home. Modifier 95 should not be appended to the facility claim as the HCPCS codes distinguishes the visit as a telehealth service.
Have there been any additions to the list of eligible practitioners who can furnish and bill for Medicare telehealth services?
SunStone Response:
Yes. Updated waivers have expanded the types of healthcare professionals that can furnish distant site telehealth services, to include all those that are eligible to bill Medicare for their professional services, including physical therapists, occupational therapists, speech language pathologists and others.
HOSPITAL OUTPATIENT CLINICAL STAFF SERVICES
How do hospitals bill for outpatient services which are paid under OPPS, and are performed by clinical staff that cannot bill Medicare directly for their professional services? Can we bill for clinic visits with G0463 if we can perform the services remotely?
SunStone Response:
Consistent with the CMS Hospital Without Walls initiative, hospitals may provide behavioral health and education services furnished remotely by hospital-employed professionals who cannot bill Medicare directly for their professional services to a patient in the hospital, including a patient’s home (temporary expansion site provider-based to the hospital).
Counselors and other qualified employed hospital staff may furnish these services remotely via telecommunication technology or in person at the patient’s home so long as it has been made provider-based to the hospital (CMS-55341-IFC Section F.1.).
On a recent CMS Office Hours call, CMS clarified while these services are furnished remotely via telecommunications technology, they are not considered telehealth and clarified the example list of remote clinical services which can be rendered is not all inclusive. Clinical staff services provided remotely which are medically necessary and meet all of the requirements described by the HCPCS/CPT code definition may be billed by the hospital as if they were furnished in the hospital assuming the patient’s home has been made provider-based to the hospital. The PO modifier should be appended to indicate the service should receive the full OPPS payment amount.
How does a hospital register a patient’s home as a temporary expansion site of their provider-based department?
SunStone Response:
Under the extraordinary circumstance exception, the second IFR instructs hospitals to register the address for each relocated provider-based department, i.e. each patient’s home, by notifying their CMS Regional Office with the following elements:
The hospital’s CCN;
The address of the current PBD;
The address(es) of the relocated PBD(s);
The date which they began furnishing services at the new PBD(s);
A brief justification for the relocation and the role of the relocation in the hospital’s COVID-19 response; and
An attestation that the relocation is not inconsistent with their state’s emergency preparedness or pandemic plan.
During the COVID-19 Office Hours calls, a question was posed as to the ability to provide all of the patient information on an excel spreadsheet. CMS responded that hospitals have 120 days to submit the information and one spreadsheet would be permissible. They also indicated they would evaluate the process and provide additional information at a later date.
Do we append Modifier PO or PN on the UB04 for therapy services performed by therapy staff that are employed by the Hospital?
SunStone Response:
Modifier PO identifies the patient’s home as an excepted provider based location, and should be appended when employed hospital staff furnish services remotely via telecommunication technology. However, this requires the hospital register the patient’s home as a provider based location (CMS-55341-IFC Section F.1.) and in turn, will enable the facility to receive reimbursement as an excepted provider based location.
However, for some services (such as some therapy services) the Medicare reimbursement is not impacted by the excepted provider based location status. SunStone recommends reviewing the CPT codes to ensure they are impacted by the excepted Hospital Outpatient Department (“HOPD”) provision. If they are not impacted, we recommend appending Modifier PN, which would not require the facility to register the patient’s home as an outpatient location of the hospital.
LABORATORY TESTING
Has there been any further clarification om the proper reporting of COVID-19 specimen collection performed by office or hospital staff since CMS clarified G2023 and G2024 were only to be reported by independent labs?
SunStone Response:
CMS has acknowledged that specimen collection may occur in circumstances outside of the typical interactions between patients and professionals/staff. As such, CMS-5531-IFC Section BB now allows professional practices to utilize E&M level 99211 to report COVID-19 specimen collection for both new and established patients.
Additionally, HCPCS C9803 – Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus-2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source was established specifically for hospitals to report the specimen collection. HCPCS C9803 has been assigned status indicator Q1, meaning it will be conditionally packaged under OPPS when billed with a separately payable primary service for that encounter.
MEDICARE BENEFICIARY COST SHARING
We understand that Medicare is not requiring beneficiaries to pay their coinsurance and deductibles for COVID-19 related services during the PHE. Which services does this apply to?
SunStone Response:
The Families First Coronavirus Response Act waives cost-sharing for Medicare beneficiaries (i.e., coinsurance and deductible amounts) related to COVID-19 testing-related services.This provision is applicable from March 18, 2020 to the end of the PHE, when the medical visit with a provider, physician or other supplier result in an order for, or administration of, a COVID-19 test with HCPCS U0001, U0002, or CPT 87635.The medical services furnished alongside the order for, or administration of a COVID-19 test include any of the following categories of E&M 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
The waiver of cost-sharing applies to the above medical visit services under OPPS, MPFS, CAH’s, RHC’s and FQHC’s.
For services furnished on March 18, 2020 through the end of the PHE, the CS modifier should be appended on applicable claim lines to identify the service as subject to this wavier for COVID-19 testing-related services. The provider should NOT charge Medicare patients the co-insurance and/or deductible amounts for those services as Medicare will reimburse the provider for those amounts.
We did not initially submit claims to Medicare for testing-related services with the CS modifier. Now that coinsurance and deductible have been waived for Medicare patients, how do we get 100% of the Medicare reimbursement if our claims were previously submitted?
SunStone Response:
CMS has instructed providers NOT to bill Medicare patients for coinsurance and/or deductible amounts resulting from these services and have advised the following:
Physicians and practitioners who did not initially submit claims with the CS modifier should notify their Medicare Administrative Contractor (“MAC”) and request to resubmit applicable professional claims with dates of service on/or after March 18, 2020 with the CS modifier to get 100% payment.
Institutional providers including hospitals, CAHs, RHCs and FQHCs who did not initially submit claims with the CS modifier must resubmit applicable lines submitted on or after March 18, 2020 with the CS modifier to get 100% payment.
Please clarify if providers may choose not to collect copayments and deductibles for telehealth visits which are unrelated to COVID-19 testing.
SunStone Response:
The Office of Inspector General (“OIG”) is providing flexibility for healthcare providers to reduce or waive copayments and deductibles associated with telehealth visits paid by federal healthcare programs during the PHE, stating it will not subject physicians and other practitioners to OIG administrative sanctions for arrangements that satisfy both of the following conditions:
A physician or other practitioner reduces or waives cost-sharing obligations (i.e., coinsurance and deductibles) that a beneficiary may owe for telehealth services furnished consistent with the then-applicable coverage and payment rules.
The telehealth services are furnished during the time period subject to the COVID-19 Declaration.
TESTING AND TREATMENT OF THE UNINSURED
What COVID-19 related services are eligible for reimbursement for the uninsured?
SunStone Response:
The Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program was established under the Coronavirus Aid, Relief, and Economic Security (“CARES”) Act for service dates on or after February 4, 2020. Subject to available funding, reimbursement will be made for qualifying testing for COVID-19 and treatment services with a primary COVID-19 diagnosis as follows:
Specimen collection, diagnostic and antibody testing;
Testing-related visits including in the following settings: office, urgent care or emergency room or telehealth;
Treatment, including office visit (including telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, DME (e.g. oxygen, ventilator), emergency ambulance transportation, non-emergent patient transfers via ambulance, and FDA-approved drugs as they become available for COVID-19 treatment and administered as part of an inpatient stay.
FDA-approved vaccine, when available.
Please clarify provider eligibility for reimbursement of services rendered to uninsured patients under the CARES Act Provider Relief Fund:
SunStone Response:
Healthcare providers who have conducted COVID-19 testing or provided treatment for uninsured COVID-19 individuals on or after February 4, 2020 can request claims reimbursement through the program electronically, and will be reimbursed generally at Medicare rates, subject to available funding. Program registration requires eligible providers to attest to the following:
You have checked for health care coverage eligibility and confirmed that the patient is uninsured. You have verified that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, and no other payer will reimburse you for COVID-19 testing and/or care for that patient.
You will accept defined program reimbursement as payment in full.
You agree not to balance bill the patient.
You agree to program terms and conditions and may be subject to post-reimbursement audit review.
Claims for the uninsured will be subject to Medicare timely filing requirements. Providers can request payment electronically for eligible services for service dates on or after February 4, 2020. Program registration information and instruction for claims submission is available at https://coviduninsuredclaim.linkhealth.com/
For purposes of receiving reimbursement for COVID-19 testing and related services who is considered “uninsured”?
SunStone Response:
The purpose of the Uninsured Program is to provide payment to providers who furnish covered testing and treatments to individuals who do not have any health care coverage at the time the services were provided (“Uninsured Individuals”). Uninsured Individuals are defined as individuals who, as of the date of service for which provider seeks payment, are not enrolled in—
A Federal health care program, including an individual who is eligible for medical assistance only because of subsection(a)(10)(A)(ii)(XXIII) of Section 1902 of the Social Security Act (individuals in families whose income is less than 250 percent of the income official poverty line); or
A group health plan or health insurance coverage offered by a health insurance issuer in the group or individual market, or a health plan offered under chapter 89 of title 5, United States Code.
GENERAL BILLING REQUIREMENTS
Please clarify when condition code DR and modifier CR should be reported?
SunStone Response:
Condition code DR is required on claims that are impacted by payer policies related to a national disaster. With the exception of telehealth services, for billing situations related to COVID-19, condition code DR is required on institutional claims where a formal waiver has been utilized.
Modifier CR indicates a service is catastrophe/disaster related and is used for Part B items and services for both institutional and non-institutional claims. With the exception of telehealth services, modifier CR is required where a formal waiver has been utilized for billing situations related to COVID-19. Medicare will not deny claims due to the presence of condition code DR or modifier CR for services/items not related to a COVID-19 waiver.
If you have any reimbursement or regulatory questions concerning COVID-19, please feel free to email Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com.