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Coronavirus (COVID-19): Changes support diagnosis, treatment

Mar 17, 2020

The focus on the response to the coronavirus (COVID-19) has primarily centered around prevention and containment but the government and commercial payors have also addressed healthcare operational matters that encourage prompt diagnosis, treatment and monitoring through billing and reimbursement modifications and expansion of telehealth services.    

CMS and commercial payors have provided an avenue for reimbursement of services offered by hospitals, physician practices and other practitioners in diagnosing, treating and monitoring patients for the coronavirus (COVID-19).  Diagnostic lab and imaging tests will be reimbursed under Medicare Part B as well as by private insurers. CMS has established reimbursement for coronavirus lab tests. The BCBS Association has waived pre-authorization and cost-sharing for testing consistent with CDC guidance and expanded access to telehealth service, and other commercial payers have followed suit. 

The CDC released interim coding guidance to support coding of encounters related to the coronavirus COVID-19 and notes that codes for conditions unrelated to the coronavirus may be needed to fully code scenarios in accordance with the current ICD-10-CM coding classification.  The CDC guidance identifies several potential illnesses that may arise based on confirmed COVID-19 infections  The list includes pneumonia, acute chronic bronchitis, lower respiratory infection, and acute respiratory distress syndrome (ARDS). Guidance is also provided to code for encounters for observation both when the exposure results in positive or negative confirmation and for treatment of symptoms when there is no definitive diagnosis, such as for cough, shortness of breath and fever.  

Starting April 1, CMS will begin accepting new HCPCS codes for laboratory tests performed on or after February 4 on patients to diagnose COVID-19. HCPCS Code U0001 is for CDC testing labs to test for SARS-CoV-2.  The additional new code, HCPCS Code U0002,  allows labs to bill for non-CDC lab tests for COVID-19.   Local MACs will set pricing for these new codes.

CMS reimbursement guidance released on March 6 was not limited to diagnostic testing, but includes reimbursement for an in-patient stay, in-patient quarantine and monitoring, ambulatory, home or other alternative site treatment and monitoring, extended supply coverage, emergency ambulance transport, items or services paid for by federal, state or local government agencies, and new anti-viral drugs and preventative vaccines.    

On March 6,  the President signed into law the emergency spending bill: ‘‘Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020’’ which includes emergency waivers of certain telehealth requirements under Section 101:  ‘‘Telehealth Services During Certain Emergency Periods Act of 2020.’’ (Pub. Law No. 116-123)   The telehealth emergency law is primarily related to the coronavirus national public health emergency declared by Secretary Azar and gives HHS the authority to waive certain telehealth restrictions in the event of declarations of emergency.  Current telehealth Medicare law limits the originating site for telehealth to specific geographic areas and locations and prohibits delivery of telehealth by phone.

The emergency law waives the originating site requirement for telehealth services permitting Medicare patients to receive telehealth services from home provided by a “qualifying provider” and through the use of a cell-phone with audio-video interaction, a capability provided by most smartphones.  While this emergency provision expands the door for telehealth in emergency situations, reimbursement for telehealth under this law is limited to services: (1) during the emergency period and in the emergency area identified by the president and the HHS Secretary; (2) provided by a physician or other practitioner (or another provider under the same TIN) who has provided Medicare services to the patient in the prior three years; and (3) in compliance with state telehealth laws, such as professional licensure, scope of practice, and informed consent.   Non-Medicare and commercial payor telehealth requirements are not affected by this law.   

Use of HIPAA compliant telehealth services is also a continued requirement.  The HHS Office of Civil Rights issued guidance in February 2020 to covered entities and business associates regarding the permitted uses and disclosures of patient information that may be made to protect the public health in an emergency situation.  This guidance reminded covered entities and business associates of the obligation to “continue to implement reasonable safeguards to protect patient information against intentional or unintentional impermissible uses and disclosures” and  “apply the administrative, physical, and technical safeguards of the HIPAA Security Rule to electronic protected health information.” In a declaration of emergency, the HHS Secretary has the authority to waive sanctions and penalties for failures to comply with specified provisions of HIPAA; however, Secretary Azar has not exercised such authority at this time.  Providers should be cognizant of complying with HIPAA and applicable state data security laws in their use of telehealth services. 

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