Reimbursement-Related Questions as the COVID-19 PHE Continues

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.

This author always welcomes reimbursement-related questions from our wound/ulcer management readers. Ever since the COVID-19 public health epidemic (PHE) was declared, the number of reimbursement questions has significantly increased. This is not surprising because we are living and working in “uncharted waters” and the reimbursement guidelines keep adjusting to assist health care professionals and providers meet the health care needs of our nation. Because we always learn from each other’s questions, this article shares the most common reimbursement-related questions this author has received as the COVID-PHE continues.

Q: We are confused about the continuation of the COVID-19 PHE waivers and allowances. We thought they ended in July. Will you please clarify what, if anything, is still applicable?

A: You are correct that the entire country was hoping the coronavirus would be under control and that the COVID-19 PHE would end in July. The bad news is that the number of COVID-19 cases, hospitalizations, and deaths continued to rise in July. Therefore, effective July 25, the COVID-19 PHE was renewed for another 90 days by the Health and Human Services (HHS) secretary. The good news is that all the waivers and allowances related to the COVID-19 PHE are still effective until the HHS secretary declares that the PHE is over. Additionally, do not be surprised if additional waivers and allowances are made until the PHE ends.

Q: We currently offer COVID-19 testing in our office. Is it true that we can now be reimbursed by Medicare if we counsel patients to self-isolate (quarantine) at the time of the COVID-19 testing?

A: Yes, that is true for physicians and other qualified health care professionals (QHPs) who are qualified to report evaluation & management (E/M) services. On July 30, 2020 the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) announced that Medicare payment is available to physicians and health care providers to counsel patients (at the time of COVID-19 testing) about the importance of self-isolation after they are tested and prior to the onset of symptoms.

The counseling should include 1) a discussion about the immediate need for isolation (even before results are available), 2) the importance of informing their immediate household that they should be tested for COVID-19, 3) a review of COVID-19 signs and symptoms, and 4) services available to aid them in isolating at home.

The physicians/providers should also educate the patients, if they test positive, to always wear masks. The patients should be informed, if they test positive, that they will be contacted by public health authorities and asked 1) to provide information for contact tracing, and 2) to tell their immediate household and recent contacts in case it is appropriate for these people to be tested for the virus and to self-isolate.

The CMS advises that physicians and providers who are eligible to bill the CMS for counseling services of people with Original Medicare should use existing E/M codes  and payment policies no matter whether the test is administered in a physician’s office, urgent-care clinic, hospital, community drive-thru, or pharmacy testing site. Therefore, when furnishing these isolation counseling services during 2020, physicians and other practitioners spending more than 50% of the face-to-face time (for non-inpatient services) or more than 50% of the floor time (for inpatient services) should use “time” to select the level of visit reported.

The CMS has created an excellent Counseling Check List that includes links to information provided by the CDC and that assists with implementation of this counseling service.¹ In order to compliantly bill for the counseling services, all of the work and the time spent should be documented in the medical record. The MLN Matters article number SE20011 lists 3 other resources that should assist providers implement this isolation counseling service.² Even if you do not perform COVID-19 testing and isolation counseling, you may find the resources helpful for other areas of your practice.

Q: Is it true that physicians and other QHPs are not required to write and sign orders for services, procedures, or products during the COVID-19 PHE?  

A: No, that is not true. During the COVID-19 PHE, services, procedures, and/or products must be reasonable and necessary. Like before the PHE, documentation in the medical record should prove that the items reported on claims were ordered and provided and the medical record should be signed by the physician/QHP. This author has 2 favorite resources pertaining to signatures. Both documents are concise and answer most of the signature questions that physicians and QHPs often ask.^3,4

Q: Our group of physicians and QHPs provide wound/ulcer management services to Medicare beneficiaries in skilled nursing facilities (SNFs). During the COVID-19 PHE most of the SNFs requested that we conduct our wound/ulcer management assessments via telehealth. In some instances, we had to use the telephone for these services. We received consent from the patients, provided the time-based telephone E/M service, and reported the appropriate codes 99441–99443 on our Medicare claims. In most instances, our claims were denied because the Medicare Administrative Contractor (MAC) said that codes 99441–99443 were part of the SNFs’ consolidated billing. We are confused by these denials because the 99441–99443 codes were added to the list of telehealth codes that are coverable under the COVID-19 PHE waivers.

A: This author can understand why you are confused and can also understand why the MACs, who processed your claims, may have been confused. You are correct that the codes 99441–99443 were added to the list of telehealth codes that are covered during the COVID-19 PHE. However, the CMS forgot to add the 3 codes to File 1 of the SNF consolidated billing information. If the code(s) is/are not found in File 1, the service is subject to SNF consolidated billing and the physician/QHP must look to the SNF for payment of the service because the MAC will not pay separately for that work. That is why most of your claims for 99441–99443 were denied. However, near the end of July most of the MACs realized this mistake and began reprocessing claims for 99441–99443 with dates of service on or after March 1, 2020 that were denied due to SNF consolidated billing edits. Physicians/QHPs did not have to do anything to have their claims reprocessed. By now, you have probably received payment for those claims.

Q: Because we did not pass round 1 of a Targeted Probe and Educate (TPE) audit prior to the COVID-19 PHE, we were in the middle of round 2 of the TPE audit when the COVID-19 PHE was declared. On March 30, 2020 we read that the CMS suspended most Medicare Fee-For-Service medical reviews because of the COVID-19 PHE. Shortly after, we received a notice that our TPE audit was over and that all the claims would be paid. Should we assume that no errors were found during round 2?

A: No, that would not necessarily be a correct assumption. The MACs were instructed to close all TPE audits and to pay the claims. For your peace of mind, you might want to contact your TPE auditor and ask how your round 2 review was going before the MACs had to suspend the audits due to the COVID-19 PHE. Then you will know if your improvements were headed in the correct direction.

Even though the COVID-19 PHE has been extended until the end of October, the CMS announced that the MACs intend to resume fee-for-service post-payment reviews (around the middle of August 2020) of items/services provided before March 1, 2020. However, the TPE program will not restart until a later date that was not yet been announced. Therefore, physicians, QHPs, and all other healthcare professionals should ensure that their documentation of all services, procedures, and products is accurate and timely prior to coding and billing.

Q: In February I noticed that our Advance Beneficiary Notice of Noncoverage (ABN) Form has an expiration date of March 2020. Therefore, I did some research and learned that due to COVID-19 issues, the Office of Management and Budget (OMB) was delayed in reviewing the ABN and its instructions. Therefore, the OMB provided guidance that we should use the expired form and instructions until they could finish their review work. Do you know if the OMB has released a new ABN form and instructions?

A: You are correct. Although the OMB normally reviews the ABN, Form CMS-R-131, and the ABN instructions every 3 years, they were delayed this year due to COVID-19 issues. Then on June 24, 2020, the OMB released the revised ABN form and instructions. The only thing that changed about the ABN form is the date in the bottom left corner. However, the OMB made multiple changes to the 8 pages of ABN instructions. Therefore, you should read the revised instructions and incorporate the new form and instructions into your practice.⁵

The expiration date on the revised form is 06/30/2023. However, the mandatory implementation date has confused many people. At first the OMB said the ABN form and instructions would be mandatory effective August 31, 2020. Then the OMB extended the mandatory date until January 1, 2021. However, you may use the revised ABN form and instructions prior to the mandatory implementation deadline.

The Most Frequently Asked Question by Hospital Owned Outpatient Provider-Based Departments (PBD)

Q: What code(s) should the PBD report when remote services are provided to the Medicare beneficiary when her/his home is serving as a PBD of the hospital? We know the PBD has to ensure 1) that the patient’s home meets all of the PBD conditions of participation that were not waived, 2) that the PBD has to officially relocate the PBD service to the patient’s home, and 3) that the PBD has to register the beneficiary as a hospital outpatient, but we have received conflicting coding instructions.

A: Ever since the COVID-19 PHE waivers began and telehealth services were allowed to be provided to Medicare beneficiaries in their homes, PBDs have been asking what code they should use when they support physicians/QHPs who provide telehealth services. At first, the CMS said that the PBDs could only report the originating site telehealth code Q3014. Then on July 28, 2020, the CMS updated the document entitled “COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing.”⁶ In section LL, Hospital Billing for Remote Services, the CMS surprised many PBDs by instructing them to base the code they report on 1) the location of the physician/QHP and 2) on the service provided by the physician/QHP.

Before reading the new coding scenarios, remember that these scenarios only pertain when:
1. The patient’s home (which meets all applicable conditions of participation) has been made provider-based to the hospital.  
2. The telehealth service must be furnished by a physician/QHP who ordinarily practices in the PBD.
3. The patient must be registered as an outpatient for that encounter.
4. The PBD staff must provide administrative and clinical support for the professional telehealth service.

Scenario 1:
When a PBD supports a physician/QHP to provide a covered telehealth service from a distant site (such as the physician/QHP’s home), the PBD should report the telehealth originating site code Q3014. The CMS has clearly stated that it is not appropriate for the PBD to report HCPCS code G0463 in this scenario. NOTE: The physician/QHP should report the appropriate code for the telehealth service provided.

Scenario 2:
When the physician/QHP is in the PBD and provides an audio-video E/M service, the PBD should report the clinic visit code G0463. NOTE: The physician/QHP should report an E/M code, not a telehealth code, because the patient is considered to be located in the PBD.

Scenario 3:
During the August 11, 2020 Coronavirus COVID-19 Office Hours call, the CMS clarified one other scenario:⁷ When the physician/QHP is in the PBD and provides a telephone E/M service, the PBD should report the clinic visit code G0463. NOTE: The physician/QHP should report 99441–99443 because she/he performed the visit via the phone.

Reminder 1:

If the relocated PBD is on-campus or an excepted off-campus facility, the PBD should report modifier PO to indicate the PBD is temporarily relocated to the patient’s home and should be paid at the OPPS payment rate. NOTE: A non-excepted off-campus PBD is not eligible for a Temporary Extraordinary Circumstances Relocation Request. Therefore, that PBD (like always) should continue to report modifier PN on their claims for provided services.  

Reminder 2:

Much confusion surrounds the catastrophe/disaster related modifier CR because:
1. The CMS directed that PBDs should add the CR modifier to all claims where a CMS waiver was necessary, including claims for services furnished at relocated PBDs that are acting as temporary expansion locations during the COVID-19 PHE, and
2. The CMS also directed that the CR modifier is not necessary for Medicare telehealth services.
The CMS must understand that PBDs are confused because they said they will not deny claims due to improper use of the CR modifier during the COVID-19 PHE.

Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@bellsouth.net.

1. Centers for Medicare and Medicaid Services. Counseling Check List: https://www.cms.gov/files/document/covid-provider-patient-counseling-checklist.pdf. Last accessed August 7, 2020.
2. Centers for Medicare and Medicaid Services. Medicare Fee-For-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19): https://www.cms.gov/files/document/se20011.pdf. Last accessed August 7, 2020.
Patient 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.
Handout for Patients to Take Home: https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/318271-A_FS_KeyStepsWhenWaitingForCOVID-19Results_3.pdf.
3. Centers for Medicare and Medicaid Services. MLN Matters SE1419: Medicare Signature Requirements - Educational Resources for Health Care Professionals: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1419.pdf. Last accessed August 8, 2020.
4. Centers for Medicare and Medicaid Services. MLN Fact Sheet ICN905364: Complying with Medicare Signature Requirements: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/signature_requirements_fact_sheet_icn905364.pdf. Last accessed August 8, 2020.
5. Centers for Medicare and Medicaid Services. Revised ABN Form and Instructions: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN. Last accessed August 9, 2020.
6. Centers for Medicare and Medicaid Services. COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing: https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf. Last accessed August 16, 2020.
7. Centers for Medicare and Medicaid Services. August 11, 2020 Coronavirus COVID-19 Office Hours call: https://www.cms.gov/files/audio/covid19officehours08112020.mp3. Last accessed August 16, 2020.