ModifiedCentenePolicy N/A

Medicare FFS billing FAQs for COVID-19 testing and related services

Guidance on Medicare Fee-for-Service billing, coding, and payment policies for COVID-19 specimen collection, diagnostic and serology laboratory testing, and related billing rules during the COVID-19 Public Health Emergency (PHE); applies to Medicare providers, laboratories, and contractors.

Policy Summary

PayerCentene

PolicyMedicare FFS billing FAQs for COVID-19 testing and related services

Policy CodePolicy N/A

Change TypeMaterial additions and clarifications to PHE billing, coding, and payment rules

Effective DateN/A

Next Review DateN/A

Key ActionLaboratories must report U0005 on the same claim as U0003 or U0004 and meet per-test and monthly timeliness criteria to bill the add-on.

SourceLink

POLICY UPDATE CHANGES

Two new HCPCS specimen collection codes (G2023, G2024) and travel allowance rules are established for COVID-19 specimen collection during the PHE.

New laboratory test codes for COVID-19: U0001, U0002, CPT 87635, and serology CPT codes 86328 and 86769, with MACs setting interim payment rates.

Two new CPT codes (86328, 86769) were announced for COVID-19 antibody (serology) testing.

CMS created HCPCS U0003 and U0004 for COVID-19 high-throughput CDLTs and U0005 as an add-on payment when timeliness criteria are met.

Payment rates for high-throughput HCPCS codes were revised: base payment lowered to $75 and add-on $25 available starting Jan 1, 2021.

Hospitals and ASCs may use temporary expansion sites for inpatient and outpatient services during the PHE and bill Medicare as if services were at permanent hospital locations if CoPs are met.

CMS will increase the IPPS MS-DRG relative weight by 20% for discharges of patients diagnosed with COVID-19 during the PHE.

Acute care hospitals may house psychiatric or acute patients in excluded distinct part units during the emergency and should bill under the original payment system while annotating the medical record.

Patient status code '69' should be used when transferring Medicare patients to temporary care sites operated by public entities; claims with code '69' do not receive a transfer adjustment.

CMS will exclude all Parts A and B FFS payment amounts for an episode of care triggered by an inpatient service for treatment of COVID-19 from Shared Savings Program financial calculations.

Expanded list of primary care service codes for beneficiary assignment to include telehealth and technology-based services (G2010, G2012, 99421-99423, 99441-99443) for performance years during the PHE.

Application of the Extreme and Uncontrollable Circumstances Policy to shared losses: shared losses are mitigated proportionally to the duration of the PHE.

CMS will not apply the two percent sequestration reduction to ACO shared savings payments for the suspension period (claims with dates of service May 1–Dec 31, 2020).

Claims for inpatient COVID-19 treatment that occur in SNFs acting as inpatient acute care or under arrangements will trigger excluded COVID-19 episodes of care.

Episode of care length is defined in months: month of admission through month following discharge for exclusions from Shared Savings calculations.

CMS delayed multiple Medicare cost report filing deadlines and granted 60-day extensions for reporting periods ending March 1–Dec 31, 2020.

Medicare will pay for monoclonal antibody products authorized under an EUA to treat COVID-19 and for their administration under Part B consistent with Section 3713 of the CARES Act.

Allowed practitioners (NPs, PAs, CNSs) may certify, order, and recertify home health services beginning March 1, 2020; this change was made permanent by CARES Act section 3708.

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G2023/G2024HCPCS specimen collection codes established for PHE

U0001,U0002,87635,86328,86769COVID-19 lab & serology codes available

U0003/U0004/U0005High-throughput HCPCS

51%U0005 timeliness threshold

20%MS-DRG weight increase for COVID-19 discharges

NCApplicable state listed

Coverage and Billing Criteria During the PHE

Covered when ALL of the following groups of CMS COVID-19 PHE coverage and billing criteria are met. Consolidated summary of provider billing rules, codes, supervision and special payment adjustments during the PHE.

ALL of the following

Specimen collection and laboratory testing
- Independent laboratories may bill the nominal specimen collection fee for COVID-19 testing when trained laboratory personnel collect the specimen from a homebound beneficiary or a non-hospital inpatient (including non-covered SNF stays) and the specimen is not patient-collected.
  Use HCPCS codes G2023 for general specimen collection and G2024 for specimens from individuals in SNF non-covered stays or collected on behalf of an HHA. Travel allowance codes P9603/P9604 apply when applicable.
- For certain COVID-19 and related clinical diagnostic laboratory tests, CMS removed the treating practitioner order requirement for the initial test during the PHE; Medicare will cover one initial test without an order but requires an order for subsequent tests unless ordered by an authorized pharmacist or other state-authorized professional.
  Check MAC/LCDs for local coverage exclusions; laboratories should confirm ordering requirements and code lists with MACs.
- Use AMA CPT and HCPCS codes established for SARS-CoV-2 testing and serology (e.g., U0001/U0002 where appropriate; U0003/U0004 for high-throughput CDLTs; U0005 as the high-throughput add-on when criteria met; CPT 86328 and 86769 for serology).
  Local MACs set interim payment amounts for new CPT codes until CLFS establishes national rates; U0003/U0004 paid at $75; U0005 add-on $25 when throughput and turnaround criteria met.
Telehealth, remote services, and originating site
- Medicare expanded telehealth during the PHE to allow services on the PFS telehealth list to be furnished to beneficiaries in their homes and other settings; audio-only billing is allowed for specified codes (telephone E/M, certain behavioral health, DSMT, and Communication Technology-Based Services).
  Providers should use the telehealth code list and apply applicable modifiers/PO S per guidance; distant-site practitioners report the POS that would have been used in-person.
- RHCs/FQHCs can bill distant-site telehealth services using G2025 and may bill G0071 for online digital E/M at the published rate ($24.76) with frequency limits (not more than once per 7 days).
  G0071 effective for services on/after March 1, 2020; claims submitted earlier will be reprocessed when systems update.
- Hospitals generally do not bill professional telehealth services; hospitals may bill originating site facility fee (Q3014/Q3104) for registered outpatients receiving telehealth from a distant-site practitioner, and may bill hospital outpatient services as if furnished in-hospital when the patient's home is registered as a provider-based department under Hospital Without Walls.
  Append CR/DR modifiers and DR condition code as applicable for services related to COVID-19 waivers; hospitals should follow UB-04 billing and PO/PN modifier guidance for home-as-PBD.
Supervision, teaching physicians, scope of practice
- During the PHE, 'direct supervision' may be satisfied via interactive audio/video technologies; CMS allowed virtual direct supervision and expanded general supervision flexibilities for many services beginning March 1, 2020 for the duration of the PHE.
  Applies to Physician Fee Schedule services, hospital outpatient services, rehabilitation, and select therapy services; documentation of supervision should be maintained.
- Teaching physician rules were relaxed to permit presence during the critical/key portion via interactive telecommunications; residents may furnish telehealth and certain services under the primary care exception with remote review as permitted during the PHE.
  Residency time counting for IME/DGME and moonlighting billing protections were modified; hospitals may claim residents in FTE counts when deployed to other hospitals per guidance.
- Scope of practice: CMS interim policy allowed additional non-physician clinicians (NPs, PAs, CNSs, CRNAs, CNMs) to supervise diagnostic tests per state law and expanded pharmacists' role as auxiliary personnel incident to billing practitioner services where applicable.
  State scope-of-practice and licensure rules still apply.
IPPS adjustments, NCTAP, and temporary site billing
- CMS implemented a temporary 20% increase to the MS-DRG relative weight for discharges of patients diagnosed with COVID-19 under CARES Act section 3710 for the emergency period; no DR condition code required; MACs will reprocess eligible claims automatically.
  Identification uses ICD-10-CM codes B97.29 (1/27/20–3/31/20) and U07.1 (4/1/20 onward) present on the claim in any diagnosis field.
- New COVID-19 Treatments Add-on Payment (NCTAP) provides enhanced outlier-related payment for inpatient cases using eligible new COVID-19 products; monoclonal antibody products paid under Part B vaccine-like methodology and are not eligible for NCTAP.
  CMS expects initial monoclonal antibodies to be provided free; Medicare pays separately for administration (infusion) consistent with EUA; preliminary outpatient administration payment approx $310—subject to refinement.
- Hospitals may provide inpatient/outpatient services at temporary expansion sites (Hospital Without Walls) and bill Medicare as if furnished at permanent locations when CoPs are met and waivers invoked; temporary expansion sites should be reported with DR condition code and CR modifier as applicable for claims.
  For relocated PBDs, hospitals do not need updated enrollment during the PHE but must follow extraordinary relocation processes if seeking permanence post-PHE.
Ambulance and EMT flexibilities
- Ambulance destinations were expanded during the PHE to include temporary expansion sites, the beneficiary's home, and other alternative destinations equipped per local EMS protocols; Medicare may pay for transports to these destinations when medically necessary.
  Medicare waived certain vehicle/staffing licensure requirements to the extent states permit; cross-state staff certification waiver applies when equivalent out-of-state licensure exists and not excluded.
- Ground Ambulance Data Collection reporting period was modified (Year 1 shifted to 2021) and reporting deadlines extended; the 10% payment reduction for failure to report still applies absent a hardship exemption.
  Selected organizations must select a new 12-month collection period in 2021 per CMS guidance.
Facility-specific billing: RHC/FQHC, Home Health, Hospice, SNF, IRF
- Specimen collection is not separately payable in RHCs/FQHCs (included in all-inclusive rate/PPS) and these centers bill telehealth via G2025 for distant-site services; RHC productivity exceptions may be granted by MACs for PHE-related disruptions.
  RHC/FQHC distant-site telehealth payment set at $92.03 as applicable.
- Home health agencies may use telecommunications for assessments and some services during the PHE (must remain on plan of care); initial and comprehensive assessments may be conducted remotely under interim waivers; only in-person visits are reported on home health claims though cost reporting flexibilities permit HHAs to record telecommunication costs as A&G items on cost report.duration: PHE
  Allowed practitioners (NP/PA/CNS) may certify eligibility and order home health services per CARES Act changes; direct supervision may include virtual presence.
- Hospices, SNFs, and IRFs received specific flexibilities: hospice may use telecom for routine home care (with limits for face-to-face recertification), SNF 3-day qualifying stay waiver applies broadly, and IRFs had the 3‑hour rule waived and classification/coverage flexibilities to relieve acute care capacity depending on phase guidance.
  Freestanding IRFs documenting patients admitted solely to relieve hospital capacity should annotate records (append 'DS' to patient identifier) and follow phase-specific payment/billing rules.
Drugs, vaccines, and monoclonal antibodies under Part B
- COVID-19 vaccines and monoclonal antibody products are covered under Part B during the PHE without beneficiary cost-sharing; payment for products provided free to providers is not made, but administration (infusion) is paid separately consistent with EUA and setting-specific methodologies (reasonable cost or AWP-based rules described by CMS).
  CMS will publish Level II HCPCS codes for monoclonal antibodies and administration; when product is free, do not include the product HCPCS on the claim; providers should hold claims until product-specific codes are published if needed.
- Medicare initial national average administration payment for certain monoclonal antibody infusions approximated $310 (hospital outpatient basis) but may be revised; payment rates and setting-specific rules are maintained on the CMS COVID-19 vaccines and monoclonal antibodies page.
  Documentation must support EUA-consistent use and medical necessity; for MA enrollees, providers should bill Original Medicare per CARES Act Section 3713 requirements.
Cost reporting, PRF, SBA reporting and treatment of relief funds
- CMS extended cost report filing deadlines for multiple FYEs during the PHE and allowed 60-day extensions for cost reporting periods ending March 1–Dec 31, 2020; PRF payments and SBA loan forgiveness amounts must be reported as revenue on specified cost report worksheets for informational purposes and generally should not offset expenses on the Medicare cost report.
  Providers must follow HRSA guidance for appropriate PRF uses and reporting; certain PRF Uninsured Program reimbursements are excluded from Worksheet S-10 per CMS guidance.
- Provider Relief Fund amounts that are not patient-specific and SBA loan forgiveness should not be used to offset Medicare cost report expenses except where specifically attributable to claims; questions regarding overpayments directed to HRSA.

Codes, Modifiers, and Payment Parameters

Operational Steps, Billing Actions, and Notifications for Providers

Documentation Required

One test without order; orders required thereafter

Each beneficiary may receive one COVID-19 (and related) clinical diagnostic laboratory test without a practitioner order during the PHE; subsequent COVID-19 and related tests require an order from a physician or other authorized practitioner. CMS will also pay when tests are ordered by pharmacists or other healthcare professionals authorized under state law.

Billing Rule

Bill from temporary expansion (surge) locations under hospital CCN

Hospitals may begin billing Medicare for services furnished in temporary expansion or surge locations under the hospital's existing CMS Certification Number (CCN) for care furnished during the PHE; ASCs converting to hospitals should contact their MAC for enrollment guidance.

Key Definitions and Terminology

inv-111: Homebound

Homebound definition (policy)Beneficiary is 'confined to the home' if it is medically contraindicated for the patient to leave home; normal inability to leave and leaving would require considerable and taxing effort; self-quarantine alone does not qualify unless medically contraindicated

ExamplesApplies when physician determines patient has confirmed/suspected COVID-19 or patient has condition making them more susceptible to infection

DocumentationMedical determination supporting homebound status should be in medical record for specimen collection fee eligibility

inv-112: High throughput technology

High-throughput technology definitionA high-throughput technology uses a platform that employs automated processing of more than 200 specimens per day

Use in coding

Policy Summary

PayerCentene

PolicyMedicare FFS billing FAQs for COVID-19 testing and related services

Policy CodePolicy N/A

Change TypeMaterial additions and clarifications to PHE billing, coding, and payment rules

Effective DateN/A

Next Review DateN/A

Key ActionLaboratories must report U0005 on the same claim as U0003 or U0004 and meet per-test and monthly timeliness criteria to bill the add-on.

SourceLink

On This Page

Billing Rule

U0005 must be billed with U0003/U0004 and timeliness criteria

Laboratories seeking the $25 add-on (U0005) must report U0005 on the same claim as U0003 or U0004 and meet both the per-test 2-calendar-day completion requirement and the monthly majority timeliness threshold.

U0005 billed only with U0003 or U0004 on same claim
Per-test completion: results finalized within 2 calendar days of specimen collection
Monthly requirement: majority (≥51%) of high-throughput CDLTs completed within 2 calendar days in prior calendar month

Documentation Required

Annotate records and bill under appropriate inpatient system for relocated patients

Annotate the medical record when psychiatric inpatients are cared for in acute care beds or when acute care patients are housed in excluded distinct-part IRF units due to the emergency; bill these patients under the appropriate inpatient payment system and document the emergency-related relocation.

Psychiatric patients relocated to acute care beds: bill under IPF PPS and annotate record
Acute care patients housed in excluded IRF units: bill under IPPS and annotate record

Billing Rule

Use patient status code '69' for transfers to disaster alternative care sites

Use patient status code '69' on inpatient claims when transferring Medicare-enrolled patients to temporary care sites operated by public entities (designated disaster alternative care sites); claims submitted with code '69' will not receive a transfer adjustment.

Billing Rule

Outpatient COVID-19 tests fall within inpatient payment windows

Hospitals generally may not bill and receive separate Medicare FFS payment for COVID-19 testing provided in the outpatient department on the day of, the day immediately preceding, and (for most hospitals) the two days prior to an inpatient admission; CAHs are exempt and may bill separately.

Billing Rule

Report Condition Code 44 when appropriate

Condition Code 44 remains applicable despite the waiver of the utilization review condition of participation; hospitals must report Condition Code 44 where appropriate.

Billing Rule

Bill relocated off‑campus PBDs with PO (excepted) or PN (non‑excepted)

Hospitals may immediately furnish services at relocated off‑campus provider‑based departments (PBDs) and bill using the PO modifier if applying for the temporary extraordinary circumstances relocation exception; if not applying (or denied), bill with PN.

If applying for temporary exception: use PO modifier and receive OPPS payment rate
If not eligible or denied: bill with PN modifier

Documentation Required

Notify CMS regional office within 120 days with specified relocation details

Within 120 days of beginning to furnish and bill at a relocated off‑campus PBD, hospitals must email their CMS Regional Office and include CCN, start date, original and new addresses, justification/role in addressing COVID-19, attestation re: state plan consistency, and a hospital point of contact.

Billing Rule

Apply DR (institutional) and CR (professional) codes for COVID‑19 waiver‑related claims

Add the DR condition code at the institutional claim level and the CR modifier on professional (Part B) claims, as applicable, when CMS waivers were necessary for temporary expansion locations and relocated PBDs during the PHE.

DR = institutional claim-level code when all services on claim relate to a COVID‑19 waiver
CR = Part B line-item modifier identifying services related to a COVID‑19 waiver

Billing Rule

Add CR/DR for relocated PBDs; enrollment not required during PHE

Hospitals must add CR/DR modifiers/condition codes to claims where CMS waivers are applicable for relocated PBDs acting as temporary expansion locations; no CMS‑855A enrollment required during the PHE if billing under main hospital.

No additional provider enrollment actions required for relocated excepted PBDs billing under main hospital during PHE
Permanent relocations after PHE may require CMS‑855A and standard extraordinary circumstances process

Billing Rule

Bill services at Hospital Without Walls temporary expansion sites and append DR/CR

Hospitals operating temporary expansion sites built/retrofitted by public entities may bill Medicare for covered inpatient and outpatient services at those sites; add DR condition code to institutional claims and CR modifier to practitioners' professional claims and use appropriate POS codes.

Billing Rule

Bill home provider‑based HOPD services as hospital outpatient with PO/PN and DR/CR

Hospitals may bill for clinical staff services furnished in a patient's home when the home is made provider‑based to the hospital and the patient is registered as a hospital outpatient; bill as if furnished in the hospital, include PO/PN and DR/CR as applicable.

Billing Rule

PHP remote provision allowed; bill as hospital/CMHC with DR and follow PHP requirements

Partial Hospitalization Program services may be furnished remotely (audio-video preferred; audio-only only when video not possible) and billed as if furnished in the hospital/CMHC with the DR condition code; other PHP requirements (orders, supervision, plan of treatment) remain in effect.

PHP remote services effective March 1, 2020; audio‑video preferred
If audio-video unavailable, audio-only permitted to maintain access
Bill remotely furnished PHP services with DR condition code

Billing Rule

Ambulance destinations expanded during PHE; transport must be medically necessary

During the PHE, covered ground ambulance destinations were expanded to include alternative sites equipped to treat the patient consistent with state/local EMS protocols (examples include community mental health centers, FQHCs, RHCs, physician offices, urgent care, ASCs, and the beneficiary's home); transports must be medically necessary for coverage.

Documentation Required

Ambulance staff signature accepted with documented verbal consent in limited cases

When verbal consent is given by a patient or authorized representative and device disinfection is impractical, CMS will accept the ambulance transport staff's signature if documented; providers should note verbal consent in documentation.

Billing Rule

Ambulance vehicle, staffing, and cross‑state certification waivers subject to state law

Medicare waives certain ambulance vehicle licensing and staffing certification requirements to the extent permitted by state/local law during the PHE; alternative staffing and out‑of‑state equivalent certifications accepted if state/local law allows and staff are not excluded.

Vehicle/license waivers apply only if state/local law permits
Staffing certification waivers acceptable per state/local authority
Out‑of‑state equivalent certifications accepted if not excluded

Documentation Required

Ground ambulance data collection delayed to 2021; 10% penalty for non‑reporting

CMS modified the Medicare Ground Ambulance Data Collection timeline so Year 1 selected organizations may choose a new 12‑month collection period beginning in 2021 and corresponding reporting period; selected organizations that fail to submit required data without hardship may face a 10% payment reduction.

Year 1 organizations must select new continuous 12‑month period beginning in 2021
10% payment reduction applies for failure to report without hardship exemption

Billing Rule

Ambulance personnel licensure waiver when equivalent out‑of‑state certification exists

During the PHE, ambulance vehicle personnel licensing at 42 CFR §410.41(b) is waived for Medicare payment purposes if staff hold equivalent out‑of‑state licensure and are not affirmatively excluded; this does not override state/local law.

Billing Rule

Selected ground ambulance organizations must report in 2021 or face 10% payment reduction

Ground ambulance organizations selected for Year 1 must select a new 12‑month data collection period in 2021 and submit data during the corresponding reporting period; failure to submit required data may result in a 10% Medicare Part B Ambulance Fee Schedule payment reduction in the following calendar year unless granted a hardship exemption.

Billing Rule

RHC/FQHC distant‑site telehealth billing and G0071 rules

RHCs and FQHCs may furnish and bill distant‑site telehealth services (use HCPCS G2025) and bill online digital E/M/virtual communication services using G0071 (payment $24.76, no more than once every 7 days); report telehealth costs on cost reports as instructed.

G0071 payment rate $24.76; billable once per 7‑day period
RHCs/FQHCs can serve as distant site for Medicare telehealth services
Report distant and originating site telehealth costs on cost report forms

Billing Rule

Expanded telehealth provider eligibility and audio‑only payment during PHE

Medicare telehealth services may be furnished by physicians and many non‑physician practitioners (including newly authorized therapist categories); certain audio‑only telephone E/M codes (e.g., 99441‑99443 and 98966‑98968) are payable during the PHE.

Billing Rule

Use CR modifier and appropriate POS for temporary expansion professional claims

Add modifier 'CR' to professional claims for patients treated in temporary expansion sites during the PHE and use the applicable place of service code; hospital should report originating site facility fee per MAC guidance when applicable.

CR modifier on professional (Part B) claims for temporary expansion sites
Use POS that reflects where service would have been provided in person
Hospitals bill MAC for originating site facility fee on 12x TOB per guidance

Billing Rule

Bill originating site facility fee via MAC on 12x type of bill

Hospitals should bill their MAC for the telehealth originating site facility fee (Q3014/Q3104 guidance) on a 12x type of bill using the date of discharge as the line item date of service per CMS instructions.

Billing Rule

ACO operational elections and submissions via ACO‑MS

ACOs must log into ACO‑MS to make voluntary elections (e.g., agreement extension, freeze BASIC track level), apply for SNF 3‑day rule waivers or Beneficiary Incentive Program, submit participant/SNF affiliate changes, and follow specified submission windows.

Elect voluntary one‑year extension in ACO‑MS
Apply for SNF 3‑day rule waiver or Beneficiary Incentive Program via provided forms

Billing Rule

Follow specified timelines for ACO change requests and RFIs

Change request submission windows and RFI response periods for ACO participation options are specified (e.g., initial submission 6/19–7/20/20; RFI‑1 8/11–8/24/20; final disposition 10/20/20); ACOs should monitor ACO‑MS for exact dates.

Billing Rule

Append 'DS' to IRF patient identifier for admissions to relieve hospital capacity

Freestanding IRFs admitting patients solely to alleviate acute care hospital capacity must append the suffix 'DS' to the patient's unique patient identifier to designate that admission and document it in the medical record.

Billing Rule

IRF 3‑hour rule waived during the PHE

The IRF '3‑hour rule' (42 CFR 412.622(a)(3)) is waived for all IRF admissions during the PHE under CARES Act section 3711(a); facilities should document accordingly.

Billing Rule

OTP periodic assessment (G2077) allowed via telehealth (audio‑video or audio‑only)

Opioid Treatment Program periodic assessment code G2077 may be furnished via two‑way interactive audio‑video, or audio‑only when video is unavailable, for the duration of the PHE.

Billing Rule

Use DR (claim level) and CR (Part B line) for COVID‑19 waiver‑related billing

Use DR condition code at the institutional claim level when all services on the claim relate to a COVID‑19 waiver and append the CR modifier to Part B line items that relate to a COVID‑19 waiver; telehealth exceptions apply.

Billing Rule

Remote SNF services allowed but remain subject to consolidated billing

Therapy and clinical social worker visits to Part A SNF residents may be furnished remotely consistent with state scope‑of‑practice rules, but such remotely furnished services remain subject to SNF consolidated billing when provided during a Part A stay.

Documentation Required

Telecommunications allowed in home health but do not replace required in‑person visits

Home health agencies may use telecommunications technology for patient care during the PHE but must not substitute required in‑person visits ordered on the plan of care; only in‑person visits are reported on the home health claim, and telehealth use must be documented on the plan of care.

Billing Rule

Allowed practitioners may certify/order home health and bill G‑codes

Allowed practitioners (NPs, PAs, CNSs) may certify, order, and recertify home health services and bill G0179/G0180/G0181 for certification/oversight for dates of service on or after March 1, 2020.

G0179/G0180/G0181 usable by NPs, PAs, CNSs for home health certification/oversight
Effective for dates of service March 1, 2020 and later

Documentation Required

Enroll as mass immunizer to bill for COVID‑19 vaccines/monoclonal infusions

If not currently able to bill for Part B vaccines, enroll as a COVID‑19 vaccine provider (mass immunizer) to administer and bill for COVID‑19 vaccines and monoclonal antibody infusions; contact your MAC for enrollment assistance and follow mass immunizer enrollment instructions.

Billing Rule

SNF consolidated billing enforcement discretion allows outside entities to bill Part B directly

CMS will exercise enforcement discretion to allow entities other than SNFs (e.g., pharmacies, infusion centers, home health agencies) to bill Medicare directly for monoclonal antibody products and their administration to Part A SNF residents during the enforcement discretion period.

Billing Rule

Face‑to‑face encounter requirements relaxed during PHE; document medical necessity

CMS will generally not enforce face‑to‑face or in‑person encounter requirements in NCDs/LCDs during the PHE (with statutory exceptions); providers must still document medical necessity in the medical record.

Billing Rule

Home infusion and virtual direct supervision allowed; billing to billing practitioner

Physicians may furnish injected or infused drugs in the patient's home and use auxiliary personnel under direct supervision provided via interactive audio‑video technology during the PHE; billing practitioner receives Medicare payment under the PFS and remains responsible for payment arrangements with contracted entities.

Documentation Required

Practitioner signature required on DMEPOS orders; electronic signatures allowed

DMEPOS orders require a practitioner's signature prior to claim submission; electronic signatures are acceptable during the PHE.

Billing Rule

Notify MAC in writing when reverting from temporary hospital to ASC

If an ASC enrolled as a hospital during the PHE reverts to ASC status, notify your MAC in writing with facility identifiers and requested deactivation date; ASC billing privileges restored as of postmark date (processing lag possible) and ASC must comply with ASC Conditions for Coverage before billing privileges are restored.

Billing Rule

AAP/CAAP recoupment timelines and options for extended repayment

Accelerated and Advance Payments (AAP/CAAP) are subject to recoupment timelines; providers may work with their MAC for extended repayment schedules if experiencing hardship, though interest accrues after demand letter.

Billing Rule

Outpatient therapy telehealth billing: follow consolidated billing and -95/PO/PN guidance

Outpatient therapy furnished via telehealth remains subject to consolidated billing rules: therapy during a SNF Part A stay is bundled into SNF PPS; therapy under a home health plan of care is bundled into HHA payment; hospitals may bill telehealth therapy on UB‑04 with '-95' modifier or register patient's home as provider‑based and bill as hospital outpatient per options described.

When billing telehealth therapy on UB‑04 use -95 modifier on institutional claim lines for separately paid telehealth therapy
Therapy to Part A SNF residents remains bundled into SNF PPS

Billing Rule

Use specified provider bill types for outpatient therapy billing

Use appropriate bill types when billing for outpatient therapy services: Hospital 12X/13X, SNF 22X/23X, CAH 85X, CORF 75X, ORF 74X, HHA 34X; HHA may bill outpatient PT/OT/SLP only when patient is not under a home health plan of care.

Billing Rule

IHS hospitals: use TOB 013x and AIR guidance for COVID‑19 specimen collection/testing

IHS hospitals should use Type of Bill 013x (13X) to report charges for COVID‑19 specimen collection (HCPCS C9803) and diagnostic testing under revenue code 0510, include 'CS' modifier as applicable to waive beneficiary cost‑sharing; if the IHS hospital purchases diagnostic services, the reference lab bills the hospital and the hospital bills Medicare under the AIR (reference lab cannot bill Medicare directly).

Labs must ensure their platforms meet this definition to bill U0003/U0004 for high-throughput CDLTs

Not limited listCMS list of examples is illustrative; technologies not limited to those listed in the Ruling

inv-113: Test completion

Test completion definitionA test is 'complete' when results are finalized and ready for release; this metric is used to determine the 2-calendar-day timeliness for U0005 eligibility

Timeliness windowCounted from specimen collection day (day 0); day 2 deadline is 11:59 PM of second calendar day after collection

Billing implicationOnly tests completed within this timeframe count toward per-test eligibility for U0005 and toward monthly majority calculations

inv-114: Excluded IRF unit

Excluded IRF unit usageWhen acute care patients are housed in excluded distinct part IRF units during the emergency, hospitals should annotate the medical record and bill under the appropriate inpatient payment system (IPPS); such patients need not meet IRF coverage/60% rule during emergency

Documentation requirementMedical record must indicate patient is acute care inpatient housed in excluded IRF unit related to the emergency

Effect on IRF rulesThese patients are excluded from certain IRF coverage requirements such as the 60% rule for the emergency period

inv-115: COVID-19 diagnosis codes

COVID-19 diagnosis codes for identificationUse B97.29 for discharges Jan 27–Mar 31, 2020 and U07.1 for discharges on/after Apr 1, 2020 to identify COVID-19 cases

Use in episode/DRG adjustmentsPresence of these codes (principal or secondary) triggers IPPS 20% MS-DRG weight increase and inclusion in episode identification

Claims processing noteMACs will reprocess affected claims identified by these diagnosis codes to apply adjustments where applicable

inv-116: Temporary Extraordinary Circumstances Relocation Request

Temporary Extraordinary Circumstances Relocation Request (TER) overviewStreamlined CMS process allowing hospitals to begin furnishing and billing at relocated on-campus or excepted off-campus PBDs immediately and apply to retain excepted status within 120 days

Notification timeline and required infoWithin 120 days of starting to bill at relocated PBDs, hospital must email CMS Regional Office with CCN, start date, original and new addresses, justification, attestation re: state plan consistency, and contact info

Home as relocated PBDA patient's home can be considered a relocated PBD; if Regional Office approves under TER, hospital may bill with 'PO' modifier and receive OPPS payment; otherwise location is non-excepted (PN)

inv-117: NCTAP

NCTAP definitionNew COVID-19 Treatments Add-on Payment (NCTAP) provides enhanced payments for eligible inpatient cases using FDA-authorized or approved COVID-19 treatments

Eligibility requirementProduct must have FDA EUA or approval for treating COVID-19; products without EUA/approval are ineligible

Payment calculationEnhanced payment equals lesser of 65% of operating outlier threshold or 65% of cost beyond operating Medicare payment (including 20% add-on)

inv-118: DR / CR

DR (condition code) meaningDR is an institutional claim-level condition code used when all services on the claim relate to a COVID-19 waiver (mandatory for applicable waiver claims)

CR (modifier) meaningCR is a Part B line-item modifier used to identify professional services/items related to a COVID-19 waiver (mandatory where applicable)

Exception for telehealthTelehealth services are a noted exception to some DR/CR applicability rules

inv-119: ALS / ALS1 / ALS2

ALS/ALS1/ALS2 definitionsAdvanced Life Support (ALS) assessment and interventions: ALS1 = ALS assessment or at least one ALS intervention; ALS2 = higher-intensity ALS interventions or administration of multiple IV medications as defined by Medicare policy

Coverage basisAmbulance payment level is based on the level of service provided (ALS vs BLS) and medical necessity, not solely on COVID-19 status

ALS assessment noteAn ALS assessment may qualify transport for ALS emergency level even if no ALS intervention was ultimately provided, if medically necessary

inv-120: Approved destination

Approved destination (ambulance)An approved destination is a hospital, CAH, or SNF capable of providing required care per 42 CFR 410.40(f); during the PHE allowable destinations expanded to any site equipped to treat the patient consistent with state/local EMS protocols (including patient's home)

Condition for paymentThere must be a medically necessary ground ambulance transport to an approved/allowed destination for Medicare payment to apply

Examples of expanded destinationsMay include community mental health centers, FQHCs, RHCs, physician offices, urgent care, ASCs, dialysis locations, and patient home when appropriate

inv-121: Online digital evaluation and management services

Online digital E/M services (definition)Non-face-to-face, patient-initiated digital communications via patient portal requiring a clinical decision that would otherwise occur in the office (CPT 99421–99423)

RHC/FQHC billing mechanismThese online digital E/M codes are billed to RHCs/FQHCs using G0071 (payment $24.76) and may be furnished to new and established patients during the PHE

Frequency and consentG0071 covers a minimum 7-day cumulative period and cannot be billed more than once every 7 days; beneficiary consent may be obtained at time of service during the PHE

inv-122: Medicare telehealth / audio-only telehealth

Medicare telehealth (audio-video) vs audio-onlyTelehealth services generally require interactive audio-video two-way communication; during the PHE certain services (including telephone E/M) were allowed via audio-only

Policy on technologyInteractive real-time audio-video technology may be used to perform services on Medicare telehealth list; CMS removed outdated tech restrictions

Geographic/location limitationDistant site practitioners must be located within the United States for Medicare payment

inv-123: general_supervision

General supervision (temporary expanded definition)During the PHE, direct supervision may be satisfied virtually via interactive telecommunications technology; general supervision continues to mean overall direction and control without physician presence

ApplicationApplies to services paid under PFS and hospital outpatient services; effective March 1, 2020 for duration of PHE

Implication for incident-toVirtual direct supervision may be used to satisfy supervision requirements for incident-to services where permitted

inv-124: primary_care_exception

Primary care exception expansionDuring the PHE the primary care exception was expanded to include all levels of office/outpatient E/M, telephone E/M, TCM, and communication-technology services for resident supervision/payment

E/M documentation flexibilityFor telehealth office/outpatient E/M under the primary care exception, E/M level may be based on MDM or time and history/PE documentation requirements were relaxed

Use for beneficiary assignmentExpanded list of primary care codes (G2010, G2012, 99421–99423, 99441–99443, etc.) included for beneficiary assignment during performance years starting on or during the PHE

inv-125: auxiliary_personnel

Auxiliary personnel clarificationPharmacists are explicitly treated as auxiliary personnel under 'incident to' rules and may provide services incident to a billing physician/NPP under appropriate supervision and state scope-of-practice

Supervision/scope limitsServices must comply with state law and not be payable under Part D to be provided incident to Part B billing

Home infusion applicationAuxiliary personnel may be used in home infusion arrangements under direct supervision provided virtually when permitted

inv-126: Episode of care

Episode of care (Shared Savings) definitionEpisode starts in month of inpatient admission, includes all months during inpatient stay, and the month following discharge (measured in units of months)

Exclusion from ACO calculationsCMS will exclude all Parts A and B FFS payments during that episode of care for COVID-19 treatment from Shared Savings Program financial calculations

Identification of episodesEpisodes identified by IPPS-eligible discharges with COVID-19 diagnosis codes (B97.29/U07.1) or equivalent acute care discharges in non-IPPS facilities

inv-127: Primary care services (during PHE)

Primary care services included during PHEPrimary care services for beneficiary assignment now explicitly include remote evaluation of patient video/images, virtual check-ins, e-visits, and telephone E/M codes during the PHE

Codes listedExamples include G2010, G2012, 99421–99423, 99441–99443, and other CPT/HCPCS codes added to primary care list for performance years during the PHE

Effect on assignmentThese telehealth/technology-based services count toward beneficiary assignment during applicable performance years

inv-128: Episode of care (Shared Savings Program)

Episode timing for Shared Savings ProgramEpisode of care starts in month of inpatient admission, includes all months during inpatient stay, and the month following discharge; measured in units of months

Exclusion scopeAll Parts A and B FFS payment amounts during that episode are excluded from Shared Savings Program calculations

Example illustrationAdmit Mar 15, discharge Apr 17 → episode Mar 1–May 31; payments during that period excluded

inv-129: DS designation

DS designation for IRF patientsFreestanding IRFs must append 'DS' to the patient's unique patient identifier when admitting patients solely to alleviate acute care hospital capacity during the PHE

Effect of DS suffix'DS' indicates certain IRF coverage/classification requirements (e.g., 3-hour rule, 60% rule) do not apply for those patients during the emergency

Documentation requirementIRF must document that admission was solely to relieve hospital capacity and mark patient identifier accordingly

inv-130: OTP periodic assessment telehealth allowance

OTP periodic assessment telehealth allowanceHCPCS G2077 periodic assessments may be furnished via two-way interactive audio-video, or audio-only if video is unavailable during the PHE

Billing contextG2077 is an add-on periodic assessment code for OTPs and may be billed consistent with OTP billing rules during the PHE

Access rationaleAudio-only permitted only when beneficiary lacks video access to maintain access to assessments

inv-131: section 1812(f) waiver

Section 1812(f) waiver (3-day SNF) overviewSection 1812(f) waiver temporarily waives the 3-day qualifying hospital stay requirement for SNF benefits during the PHE

One-time renewal preservationIf beneficiary received a one-time renewal of SNF benefits under the waiver, the additional 100 days remain available even after the waiver expires

Consequence for eligibilityWaiver applies broadly to SNF-level beneficiaries during the emergency period; clinical judgment/documentation still required

inv-132: DR / CR

DR/CR billing guidanceUse DR condition code at the institutional claim level when all services on claim relate to a COVID-19 waiver; use CR modifier on Part B line items related to a COVID-19 waiver (mandatory except telehealth)

PurposeHelps identify claims where Medicare payment is conditioned on the presence of a formal waiver

CMS stanceMedicare will not deny claims due to presence of DR/CR on services/items not related to a COVID-19 waiver

inv-133: Allowed practitioners

Allowed practitioners for home healthAllowed practitioners (per CARES Act section 3708) who may certify/order home health are NPs, PAs, and CNSs beginning March 1, 2020

G-codes for oversightThese practitioners may bill G0179, G0180, and G0181 for certification/oversight of home health services for dates of service on/after March 1, 2020

Scope limitationSection 3708 does not expand 'allowed practitioners' beyond NPs, PAs, and CNSs for this purpose

inv-134: Monoclonal antibody infusions

Monoclonal antibody infusion payment stanceMedicare will pay for monoclonal antibody products authorized under an FDA EUA or approval and will pay separately for administration under Part B consistent with Section 3713 of the CARES Act

HCPCS codes availableCMS published Level II HCPCS codes for specific monoclonal antibodies and infusion services (e.g., Q0239/M0239 for bamlanivimab; Q0243/M0243 for casirivimab+imdevimab)

Beneficiary cost-sharingThere is no beneficiary cost sharing or deductible for these monoclonal antibody products and their administration when billed appropriately

inv-135: Modifier 25 guidance

Modifier 25 usage for same-day E/MUse modifier '25' to report a medically necessary, separately identifiable E/M service on the same day as a vaccine or infusion when applicable

ApplicabilityApplies to physicians/NPPs and hospital outpatient departments furnishing an E/M visit on same day as vaccine/infusion to identify separable E/M service

Common occurrence during PHECMS anticipates common models where testing, diagnosis, and infusion occur same day; use of modifier 25 helps distinguish E/Ms

inv-136: Face-to-face flexibilities

Face-to-face flexibilitiesDuring the COVID-19 PHE CMS will generally not enforce face-to-face or in-person encounter requirements in NCDs/LCDs (with statutory exceptions); telehealth may substitute where appropriate

Documentation still requiredMedical records must still support medical necessity and that services were provided at the billed level despite enforcement relaxation

Statutory exceptionsSome statutory face-to-face requirements (e.g., for PMDs) remain enforceable even during the PHE

inv-137: Home oxygen enforcement discretion

Home oxygen enforcement discretionClinical indications for home oxygen and certain respiratory-related NCDs/LCDs will not be enforced during the PHE to allow practitioner flexibility; enforcement resumes after PHE ends

Medical necessity still requiredProviders must document medical necessity in the medical record even when enforcement is relaxed

Limited durationThis enforcement discretion applies only for the duration of the COVID-19 PHE

inv-138: MTF billing exception

MTF billing exceptionDepartment of Defense Military Treatment Facilities generally excluded from Medicare payments, but an exception allows billing Medicare for emergency inpatient and outpatient hospital services under certain statutory provisions

Regulatory referencePayments governed by 42 C.F.R. Part 424, subpart G; CMS and DOD coordination enables many DOD hospitals to bill Medicare for COVID-19 emergency services

ScopeApplies to covered emergency services related to COVID-19 treatment and other emergency hospital services as authorized

inv-139: Telecommunications technology in hospice

Telecommunications in hospiceHospices may use telecommunications technology (e.g., two-way audio-video) for routine home care communications and, where capable, for initial and comprehensive assessments during the PHE

Face-to-face recertificationTelecommunications (two-way audio-video) can satisfy hospice face-to-face recertification encounters; audio-only is not acceptable for recertification

Claim/reporting limitsOnly in-person visits (except social work telephone calls) are reported on hospice claims; telecom costs may be reported on hospice cost report under specified cost centers labeled 'PHE for COVID-19'

inv-140: Telehealth originating/distant site

Originating vs distant site for telehealthOriginating site is where beneficiary is located; during PHE hospitals may register a patient's home as a provider-based department (PBD) and serve as originating site when COPs are met (to extent not waived)

Hospital billing for originating site facility feeHospitals may bill the telehealth originating site facility fee (Q3014) for registered hospital outpatients receiving telehealth from a distant-site practitioner

Place of service reportingDistant site practitioners should report the POS that would have been used if service furnished in person; hospitals generally do not bill telehealth professional services themselves

inv-141: Teaching hospital

Teaching hospital definition and protectionsTeaching hospital = hospital engaged in approved GME residency programs (medicine, osteopathy, dentistry, podiatry); CMS will allow sending hospitals to retain resident FTEs for IME/DGME counts during the PHE

Temporary bed exclusionBeds temporarily added during the PHE will be excluded from IME calculations to hold teaching hospitals harmless

Hold-harmless stanceCMS is holding IPF and IRF teaching status adjustment payments harmless for duration of the PHE

inv-142: Non-CBA DME pricing

Non-CBA DME pricing (definition)Non-CBA DME pricing for non-rural contiguous non-CBAs under section 3712(b) uses a blend of 75% adjusted CBP-based amount + 25% historic unadjusted amount (effective Mar 6, 2020 through the PHE)

Estimated average increaseSection 3712(b) estimated to raise fee schedule amounts ~33% on average for affected items/services

Effective periodBlend effective March 6, 2020 and remains through the duration of the COVID-19 PHE