TEMPORARY Cost-share Waiver for Visits Related to COVID-19 Diagnostic Testing
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Temporary policy waiving member cost sharing for office, urgent care, emergency, and telehealth visits that result in an order for or administration of a COVID-19 diagnostic test or evaluation to determine need for such testing; affects BCBSRI Medicare Advantage and commercial plan providers and members during the policy timeframe.
No material clinical or coverage changes in this revision.
Coverage Criteria
Cost-share waiver criteria
Covered when ALL of the following are met
Services must relate to furnishing or administration of the test or evaluation to determine need
Policy was effective 03/18/2020 and considered archived effective 11/01/2022
For line items on a claim that are not associated with an encounter for the determination of COVID-19 testing, providers should report the primary diagnosis that is specific to that service. Do not assume the visit-level COVID-19 diagnosis codes apply to unrelated, non-encounter line items. Use the appropriate diagnosis pointer to link each line item to the correct diagnosis when submitting on a CMS-1500 or equivalent electronic format.
Coding and Diagnosis
| 99201-99215 | Evaluation & Management Services |
| 99281-99285 | Emergency Department Evaluation & Management Services |
| B34.2 | Coronavirus infection, unspecified |
| B97.21 | SARS-associated coronavirus as the cause of diseases classified elsewhere |
| B97.29 | Other coronavirus as the cause of diseases classified elsewhere |
| U07.1 | COVID-19 |
| Z03.818 | Encounter for observation for suspected exposure to other biological agents ruled out |
| Z11.52 | Encounter for screening for COVID-19 (effective 1/1/2021) |
| Z11.59 | Encounter for screening for other viral diseases |
| Z20.822 | Contact with and (suspected) exposure to COVID-19 (effective 1/1/2021) |
| Z20.828 | Contact with and (suspected) exposure to other viral communicable diseases |
| CS | Medicare modifier indicating cost share waived (accepted for MA members for qualifying visits during PHE) |
| CR | Catastrophe/disaster-related modifier (requested for telemedicine/telehealth/telephone services for tracking) |
Provider Actions and Billing Requirements
Prior authorization — check BCBSRI Authorization & Referral Guidelines
Please refer to BCBSRI.com for current Authorization and Referral Guidelines requirements.
Add CR modifier for MA telemedicine/telehealth/telephone visits
For Medicare Advantage telemedicine/telehealth/telephone visits, BCBSRI requests the CR modifier to be added for tracking and consistency; this is good practice for participating providers.
Claim coding and modifiers — list policy ICD-10 as primary and use modifiers
For professional claims on CMS-1500 or equivalent, one of the ICD-10 diagnosis codes listed in this policy must be entered as the primary/first diagnosis at the line level and diagnosis pointers must be used correctly; for Medicare Advantage visits, use modifier CS for qualifying in-person visits and CR for telemedicine/telehealth/telephone services for tracking.
- Ensure one of the policy-listed ICD-10 codes is the primary/first diagnosis on the line for services related to COVID-19 testing (required for dates of service on or after 8/1/2020).
- Use diagnosis pointers correctly so claims are processed accurately.
- For MA members, add modifier CS for qualifying in-person medical visits and CR for telemedicine/telehealth/telephone services (CR requested for tracking consistency).
Denial risk — missing required primary/first listed ICD-10 diagnosis
Claims where one of the policy-listed ICD-10 diagnosis codes is not listed as the primary/first diagnosis on the line level for services related to determining COVID-19 testing may not qualify for the cost-share waiver.
- This primary/line-level requirement applies to professional providers billing on CMS-1500 or equivalent for dates of service on or after August 1, 2020.
Definitions
Background
Federal statutes and guidance — including the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act — together with subsequent federal agency FAQs, require group health plans to cover without cost sharing items and services furnished during visits that result in an order for or administration of a COVID-19 diagnostic test, to the extent those services relate to furnishing the test or evaluating the need for testing. BCBSRI implemented this temporary coverage consistent with those federal requirements.
As a result, during the timeframe this policy was in effect BCBSRI did not impose member cost sharing for qualifying office, urgent care, emergency, telemedicine/telehealth, or telephone visits that resulted in an order for or administration of a COVID-19 diagnostic test or were for evaluation to determine the need for such testing. This policy was effective 03/18/2020 and was considered archived effective 11/01/2022.
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