COVID-19: Medicare flexibilities, coding, telehealth, and waivers
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Guidance from Imperial Health Plan summarizing CMS flexibilities and operational guidance for Medicare providers during the COVID-19 public health emergency, covering accelerated/advance payments, testing and coding, telehealth/e-visits/virtual check-ins, workforce and licensing waivers, and other CMS program flexibilities that affect clinicians and facilities.
No material clinical or coverage changes in this revision.
Coverage and Payment Criteria During the COVID-19 PHE
COVERAGE CRITERIA
Coverage and payment positions during the COVID-19 PHE as described by CMS and summarized by Imperial Health Plan:
ALL of the following
- Settings and billing
Labs, physician offices, hospitals and other settings can bill for tests they perform; no copayments for testing; patients without insurance may be tested through State labs.
- Test codes
Report non-CDC tests with CPT 87635 or HCPCS U0002 depending on method; report CDC diagnostic test with HCPCS U0001.
- Diagnosis coding
Effective for services on/after April 1, 2020, report confirmed COVID-19 with diagnosis code U07.1 for positive and presumptive positive results; for services prior to April 1, 2020 follow interim guidance using applicable respiratory code plus B97.29.
ALL of the following
- Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out
- Z20.828: Contact with and (suspected) exposure to other viral communicable diseases
- Z11.59: Encounter for screening for other viral diseases
ALL of the following
- Coverage scope
During the PHE Medicare will make payments for telehealth services furnished in broadened circumstances; patients may be new or established and may be located anywhere including their home; services are the same as in-person and paid at same rate; Medicare coinsurance and deductible generally apply though providers may reduce/waive cost-sharing per OIG flexibility.
- Permitted technologies
Clinicians may use popular video chat applications (e.g., FaceTime, Skype) under HHS OCR enforcement discretion; telephone without video may be used when appropriate.
ALL of the following
- 99201-99215: Office or other outpatient E/M visits
- G0425-G0427: Telehealth consultations, emergency department or initial inpatient
- G0406-G0408: Follow up inpatient telehealth consultations for hospitals or SNFs
ALL of the following
- Separate payment for audio-only visits
For the duration of the PHE, Medicare will make separate payment for audio-only visits described by CPT codes 98966-98968 and 99441-99443.
ALL of the following
- General rules
New or established Medicare patients may have brief communication services from any location; services are expected to be initiated by the patient though practitioners may inform beneficiaries of availability; not limited to rural settings.
- G2012
Brief communication technology-based service (virtual check-in) by a physician or other qualified health care professional for 5-10 minutes of medical discussion; not originating from a related E/M in previous 7 days nor leading to an E/M within next 24 hours or soonest available appointment.
Remote evaluation of recorded video/images (store-and-forward) including interpretation with follow-up within 24 business hours; not originating from a related E/M in previous 7 days nor leading to an E/M within next 24 hours or soonest available appointment.
ALL of the following
- General rules
Patient-initiated non-face-to-face communications via online patient portal for new or established Medicare patients in any location; not a substitute for in-person visit; practitioners may educate beneficiaries about availability.
ALL of the following
- CPT 99421-99423
- HCPCS G2061-G2063
ALL of the following
- Provider eligibility criteria
Providers/suppliers may request accelerated or advance Medicare payments from their MAC if they billed Medicare within the prior 180 days, are not in bankruptcy, are not under active program integrity review or investigation, and have no outstanding delinquent Medicare overpayments.
- Payment amounts and duration
Amounts generally available up to 100% for three months; certain hospitals may be eligible for up to six months and CAHs up to 125% for six months.
ALL of the following
- CMS waivers and relaxations
CMS waived or relaxed requirements such as the 3-day SNF rule, CAH bed/LOS limits, LTCH LOS exclusions, OASIS timeframes and allowed certain cross-state provision of services for Medicare/Medicaid under conditions; these flexibilities do not override state licensing laws.
Testing, Diagnosis, Telehealth, and Billing Codes
| U07.1 | COVID-19 (use for confirmed and presumptive positive COVID-19 results) |
| 87635 | CPT: Infectious agent detection by nucleic acid (non-CDC test) — method-based (example referenced) |
| U0002 | HCPCS: Non-CDC SARS-CoV-2 test |
| U0001 | HCPCS: CDC SARS-CoV-2 test |
| B97.29 | Other coronavirus as the cause of diseases classified elsewhere (interim guidance for services prior to Apr 1, 2020) |
| Z03.818 | Encounter for observation for suspected exposure to other biological agents ruled out |
| Z20.828 | Contact with and (suspected) exposure to other viral communicable diseases |
| Z11.59 | Encounter for screening for other viral diseases |
| 99201-99215 | Office or other outpatient E/M visits (telehealth) |
| G0425-G0427 | Telehealth consultations, emergency department or initial inpatient |
| G0406-G0408 | Follow up inpatient telehealth consultations for hospitals or SNFs |
| G2012 | Brief communication technology-based service (virtual check-in) |
| G2010 | Remote evaluation of recorded video/images (store-and-forward) |
| 99421-99423 | E-visit CPT codes for online digital evaluation and management |
| G2061-G2063 | HCPCS codes for online digital E-visits |
| 98966-98968 | Telephone E/M services (audio-only) — paid separately during PHE |
| 99441-99443 | Physician telephone E/M services (audio-only) — paid separately during PHE |
Actions Providers/Suppliers Should Take
Request accelerated/advance Medicare payments from your MAC and confirm eligibility
Providers and suppliers may request accelerated payments (for providers) or advance payments (for suppliers) from their Medicare Administrative Contractor (MAC) if they meet CMS eligibility criteria. Requests must be submitted to the appropriate MAC using the Accelerated/Advanced Payment Request Document available on each MAC's website.
- Must have billed Medicare for claims within 180 days immediately prior to the date of signature on the request form.
- Must not be in bankruptcy.
- Must not be under active medical review or program integrity investigation.
- Must not have any outstanding delinquent Medicare overpayments.
- Most providers and suppliers may request up to 100% of the Medicare payment amount for a three-month period.
- Inpatient acute care hospitals, children’s hospitals, and certain cancer hospitals may request up to 100% for a six-month period.
- Critical Access Hospitals (CAH) may request up to 125% of their payment amount for a six-month period.
- MACs will prioritize states experiencing the greatest surge; the request amount is calculated per MAC instructions and submitted via the MAC-specific request document.
Key Definitions and Service Types
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