coding updates and hot topics - waystar

Copyright © 2021, Alpha II, LLC. All Rights Reserved

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Coding Updates and Hot Topics

Stuart Newsome, CPCOVice President of Strategic Partnerships

Stacey LaCottiCustomer Experience Strategist


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The content in this presentation Is current as of February 16, 2021

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New COVID-19 ICD-10 Diagnosis Codes• Released by WHO and effective 1/1/21

• Z11.52: Encounter for screening for COVID-19

• Z20.822: Contact with and (suspected) exposure to COVID-19

• Z86.16: Personal history of COVID-19

• M35.81: Multisystem inflammatory syndrome (MIS)

• M35.89: Other specified systemic involvement of connective tissue

• J12.82: Pneumonia due to coronavirus disease 2019

https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-19-508.pdf

https://www.cdc.gov/nchs/data/icd/Announcement-New-ICD-code-for-coronavirus-19-508.pdf


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New COVID-19 Testing Codes• HCPCS code U0005 for CDLTs

• Effective 1/1/21

• Add-on to testing codes U0003 and U0004

• Complete COVID-19 CDLT in 2 calendar days or less from the date of specimen collection

• Majority of COVID-19 CDLTs performed using high throughput technology in the previous calendar month were completed in 2 calendar days or less for all of their patients (not just Medicare patients)

• Labs may bill for add-on code U0005 and will be paid $100 while labs that take longer will receive a $75 payment

https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf pg. 13

https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf


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Medicare Coverage of COVID-19 Testing• Beneficiaries may receive one initial covered COVID-19 and

related test (i.e. flu) without an order from a physician or other practitioner

• Each subsequent test will require order from physician or other healthcare practitioner

• CMS will also pay for tests when ordered by a pharmacist or other healthcare professional authorized to order diagnostic laboratory tests

• List of testing codes covered under this rule can be found at www.cms.gov/files/document/covid-ifc-2-flu-rsv-codes.pdf


http://www.cms.gov/files/document/covid-ifc-2-flu-rsv-codes.pdf



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So you want to give out vaccines?

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Provider Enrollment for Vaccines and Monoclonal Antibody Products

• Mass Immunizers • Can give flu, pneumococcal, and COVID shots to groups• Likely wouldn’t be eligible for Medicare enrollment • Must submit all claims as roster billed professional claims• Examples: drug store, senior center, public health clinic

• Roster Billing• Submit multiple claims • Must administer the same type of shot to 5 or more people on

same date of service• Cannot combine multiple shots on same bill (i.e. – flu vs COVID)

https://www.cms.gov/covidvax-provider

https://www.cms.gov/covidvax-provider


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Centralized Billing Enrollment• Allows mass immunizers to send roster bill claims for flu, pneumococcal, and

COVID vaccines to single carrier regardless of where shot is administered• All claims go to Novitas and Medicare pays based on where shot was

administered• You must operate in at least 3 MAC jurisdictions and get approval from Novitas• Call Novitas at 855-247-8428

• Estimate of how many patients to whom you expect to administer the COVID-19 shot• Approximate dates of shots• List of states for COVID-19 vaccination clinics• Type of services you generally deliver other than preventive vaccinations, if any (for

example, ambulance, home health, visiting nurse)• If you employ nurses who will administer the COVID-19 shot or if you hired them

specifically to give these shots• Names and addresses of all entities operating under provider application• Contact information for the centralized billing program designated contact


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Already Enrolled in Medicare

Institutional Non-InstitutionalHospital Physician

Hospital Outpatient Department Non-Physician

SNF (A and B) Clinic/Group Practice

CAH Pharmacy (enrolled as Part B)

ESRD Facility Mass Immunizer (roster bill only)

HHA

Hospice

CORF

FQHC

RHC

Indian Health Service facility

• You don’t need to take any action to administer and bill COVID-19 shot

• Can bill individual claims or roster bill without enrolling as a mass immunizer

https://www.cms.gov/medicare/covid-19/enrollment-administering-covid-19-vaccine-shots



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Already Enrolled in Medicare But Can’t Bill Vaccines

• Already enrolled but provider type doesn’t allow for vaccine administration

• Must separately enroll as institutional or non-institutional provider type (i.e. – mass immunizer)

• Can enroll over the phone with local MAC

• Need to have the following information • Valid Legal Business Name (LBN)• NPI• TIN• Practice location and state license (if applicable)

https://www.cms.gov/files/document/covid-19-mac-webpages-and-hotlines.pdf

https://www.cms.gov/files/document/covid-19-mac-webpages-and-hotlines.pdf


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Already Enrolled in Medicare But Can’t Bill VaccinesInstitutional Non-Institutional Durable Medical Equipment

Outpatient PT Independent Clinical Laboratory Durable Medical Equipment Supplier

Occupational Therapy Ambulance Service Supplier Pharmacy (enrolled as DME supplier)

Speech Language Pathology IDTF

Histocompatibility Laboratory Ambulance Service Supplier

Religious Non-Medical Health Care Institution

Mammography Center

Medicare Diabetes Prevention Program Suppliers

Portable X-ray Supplier

Radiation Therapy Center

Opioid Treatment Program

Organ Procurement Organization

Home Infusion Therapy Supplierhttps://www.cms.gov/medicare/covid-19/enrollment-administering-covid-19-vaccine-shots



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SNF: Enforcement Discretion for Certain Pharmacy Billing • CMS is exercising enforcement discretion of SNF

consolidated billing provisions for vaccine administration

• In an effort to facilitate the efficient distribution of COVID-19 vaccines to SNF residents

• CMS will allow Medicare-enrolled immunizers to bill directly and receive direct reimbursement from the Medicare program for vaccinating Medicare SNF residents

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-12-03-mlnc-se

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-12-03-mlnc-se


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Billing for vaccines and monoclonal antibody products

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Medicare Billing for COVID-19 Vaccine Shot Administration

• Bill on single claims for COVID-19 shot administration or submit claims on a roster bill for multiple patients at one time

• Only bill for the vaccine administration when COVID-19 vaccine doses are provided by the government without charge (don’t include the vaccine codes on the claim)

• If patient is enrolled in a Medicare Advantage Plan in 2020 and 2021, submit COVID-19 claims to traditional Medicare for all patients

• There is no charge for Medicare patients (no copay/coinsurance or deductible)

• Download and install new release of PC-ACE

https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccine-shot-administration

https://www.cms.gov/files/document/covid-19-mac-hotlines.pdf

https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccine-shot-administration


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Coding for Current and Future COVID Vaccines

Pfizer-BioNTech COVID-19 Vaccine


• CPT Code 91300

• Vaccine administration codes• HCPCS code 0001A (first dose)• HCPCS code 0002A (second dose)

• 21-day dosing interval

• NDC 10/NDC 11 labeler product ID• 59267-1000-1• 59267-1000-01

https://www.ama-assn.org/system/files/2021-01/covid-19-immunizations-appendix-q-table.pdf



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Moderna COVID-19 Vaccine


• CPT Code 91301







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AstraZeneca COVID-19 Vaccine

• Not yet active

• CPT Code 91302







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Janssen COVID-19 Vaccine

• Not yet active

• CPT Code 91303

• Vaccine administration code• HCPCS code 0031A (single dose)





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Coverage of Monoclonal Antibody Products to Treat COVID-19

• Medicare will pay for monoclonal antibody products authorized for emergency use to treat COVID-19 if furnished consistent with EUA or approved by FDA

• Payment established under the CARES Act

• Effective 12/11/20, the FDA has approved:• Bamlanivimab• Casirivimab and Imdevimab (administered together)• Bamlanivimab and Etesevimab (administered together)

• Same policy would apply for any additional approved monoclonal antibody products

• Not subject to Medicare IPPS NCTAP add-on payment

https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion



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Coverage of Monoclonal Antibody Products to Treat COVID-19

• Beneficiaries have coverage without cost sharing for these products (no copay/coinsurance or deductible)

• Medicare pays for the administration (infusion) of monoclonal antibody products to treat COVID-19

• Medicare will pay the provider for these monoclonal antibody products when they are purchased by the provider

• Medicare won’t pay if the product is given to the provider for free by (i.e. from a government entity)

• Medicare Advantage plans should submit these claims to traditional Medicare

• Physician and NPP can bill for medically necessary and significantly separate E&M visit in addition to treatment (use modifier -25)




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Coding Monoclonal Antibody Products to Treat COVID-19Bamlanivimab from Eli Lilly and Company

• EUA effective 11/10/20• HCPCS code Q0239

• Injection, bamlanivimab-xxxx, 700 mg• HCPCS code M0239

• intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring

casirivimab and imdevimab from Regeneron • EUA effective 11/21/20• HCPCS code Q0243

• Injection, casirivimab and imdevimab, 2400 mg• HCPCS code M0243

• intravenous infusion, casirivimab and imdevimab, includes infusion and post administration monitoring




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Coding Monoclonal Antibody Products to Treat COVID-19

Bamlanivimab and Etesevimab from Eli Lilly and Company

• EUA effective 2/9/21• HCPCS code Q0245

• Injection, bamlanivimab and etesevimab, 2100 mg• HCPCS code M0245

• intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring




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Billing Requirements for Monoclonal Antibody Products

• Review the Emergency Use Authorization (EUA) for each drug

• Providers can bill the administration of the infusion either on a single claim or submit a roster bill

• EUA for COVID-19 monoclonal antibody treatments contain specific requirements that are considerably more complex than for other services that are billed using roster billing

• Documentation requirements• Supports medical necessity• Specifically note that terms of EUA have been met• Includes name of practitioner who ordered or made the decision to

administer the infusion (even for roster billing)




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New COVID-19 Treatments Add-on Payment (NCTAP)

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COVID-19 Treatments Add-On Payment (NCTAP)

• Effective 11/2/20 – end of PHE

• CMS established the New COVID-19 Treatments Add-on Payment (NCTAP) under the Medicare IPPS

• Medicare will provide enhanced payment for eligible inpatient cases that involve use of certain new products with current FDA approval or EUA to treat COVID-19

• The NCTAP is equal to the lesser of • 65% of the outlier threshold for claim

• 65 percent of the amount by which the costs of the case exceed the standard DRG payment (including the adjustment to the relative weight under section 3710 CARES Act for eligible cases)

https://www.cms.gov/medicare/covid-19/covid-19-treatments-add-payment-nctap



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• Eligibility criteria• Presence of ICD-10-CM diagnosis code U07.1 for COVID-19• Presence of one of the following ICD-10-PCS codes for

• Remdesivir (Veklury)• Convalescent plasma• baricitinib (Olumiant) in combination with remdesivir

• Hospitals should report the ICD-10-PCS code(s) for all products administered during the stay, regardless of whether or not the hospital received the product at no cost

• Hospitals shouldn’t report charges associated with the product received at no cost




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• CMS uses the following ICD-10-PCS codes to identify cases involving the use of remdesivir or COVID-19 convalescent plasma for hospital discharges on or after November 2, 2020:


ICD-10-PCS Code DescriptionXW033E5 Introduction of remdesivir anti-infective into peripheral vein, percutaneous approach,

new technology group 5

XW043E5 Introduction of remdesivir anti-infective into central vein, percutaneous approach, new technology group 5

XW13325 Transfusion of convalescent plasma (nonautologous) into peripheral vein, percutaneous approach, new technology group 5

XW14325 Transfusion of convalescent plasma (nonautologous) into central vein, percutaneous approach, new technology group 5



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• CMS uses the following ICD-10-PCS codes to identify cases involving the use of baricitinib for hospital discharges on or after November 19, 2020 and on or before December 31, 2020:

• Per the EUA – use of baricitinib should be administered with remdesivir and claims should also include the code for remdesivir (XW033E5 or XW043E5)


ICD-10-PCS Code DescriptionXW0DXF5 Introduction of other new technology therapeutic substance into mouth and pharynx,

external approach, new technology group 5

3E0G7GC Introduction of other therapeutic substance into upper G.I. via natural or artificial opening

3E0H7GC Introduction of other therapeutic substance into lower G.I. via natural or artificial opening



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• CMS uses the following ICD-10-PCS codes to identify cases involving the use of baricitinib for hospital discharges on or after January 01, 2021 through the duration of the COVID-19 PHE:

• Per the EUA – use of baricitinib should be administered with remdesivir and claims should also include the code for remdesivir (XW033E5 or XW043E5)


ICD-10-PCS Code DescriptionXW0DXM6 Introduction of baricitinib into mouth and pharynx, external approach, new

technology group 6

XW0G7M6 Introduction of baricitinib into upper GI, via natural or artificial opening, new technology group 6

XW0H7M6 Introduction of baricitinib into lower GI, via natural or artificial opening, new technology group 6



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COVID-19 claims reimbursement for uninsured patients

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COVID-19 Claims Reimbursement for the Uninsured• Providers can begin the process to file

reimbursement claims if they have: • Conducted COVID-19 testing or provided treatment to

patient a COVID-19 diagnosis on or after February 4, 2020

• Administered COVID-19 vaccines to uninsured individuals

• Claims are subject to Medicare timely-filing

• Medicare non-covered services will not be covered under this program

• All submitted claims must be complete and final

https://www.hrsa.gov/CovidUninsuredClaim



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COVID-19 Claims Reimbursement for the Uninsured• What’s covered:

• Specimen collection, diagnostic and antibody testing

• Testing-related visits in the following settings: office, urgent care or emergency room, or telehealth

• Treatment: office visit (including telehealth), emergency room, inpatient, outpatient/observation, SNF, LTAC, rehab care, home health, DME, emergency ambulance transport, non-emergent patient ambulance transfers, and FDA-licensed, authorized, or approved treatments as they become available for COVID-19 treatment

• Administration fees related to FDA-licensed or authorized vaccines




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COVID-19 Claims Reimbursement for the Uninsured• Providers must attest to the following:

• Check for health care coverage eligibility and confirmed that the patient is uninsured

• Verified the patient is not covered through an individual or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time services were rendered

• No other payer will reimburse you for COVID-19 vaccination, testing and/or care for that patient

• Accept defined program reimbursement as payment in full

• Can not balance bill the patient

• Agree to program terms and conditions and may be subject to post-reimbursement audit review




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General program and policy updates

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Authorization of Diagnostic Tests• In the CY 2021 final rule• CMS made permanent the rule allowing the

following clinicians to order, furnish, and supervise diagnostic tests

• NP *• CNS *• PA• CNM• CRNA (new addition)

* Must furnish professional services in collaboration with a physician




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Medicare TelehealthProfessional Telehealth Services During PHE

• For professional claims on or after March 1, 2020• POS equal to what it would have been had the service been furnished in-person

• Modifier -95 indicating service rendered was actually performed via telehealth

• Modifier -CR not required for Medicare telehealth services

• Use modifier -GQ for furnished as part of a federal telemedicine demonstration project in AK and HI using asynchronous (store and forward) technology

• Use modifier -G0 to diagnosis and treat an acute stroke

• Critical access hospital method II claims still require modifier -GT




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Telephone Assessment and Management Services• Non-physician practitioners who are eligible to bill Medicare

directly may bill for audio-only telephone assessment and management services

• Includes registered dieticians and nutrition professionals (CPT codes 98966-98968)

• Broad range of clinicians, including physicians, can now provide certain services by telephone to their patients (CPT codes 99441-99443)

• Medicare payment for telephone E&M visits is now equal to the payment for office/outpatient visits with established patients effective March 1, 2020

• Find the full list of Medicare allowable telehealth codes here

https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf


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Cost-Sharing Waivers• Cost-sharing is waived for COVID-19 testing-related services

that:• Result in an order for or administration of a COVID-19 test

• Related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test

• Are in any of the following categories of E&M codes:• Office and other outpatient services• Hospital observation services• Emergency department services• Nursing facility services• Domiciliary, rest home, or custodial care services• Home services• Online digital E&M services

https://www.cms.gov/files/document/se20011.pdf



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Coinsurance and Deductibles Waivers

• Providers should bill modifier -CS • Service subject to the cost-sharing wavier for COVID-19 testing-related

services

• Do NOT charge Medicare patients any co-insurance and/or deductible amounts for those services

• May require payer follow-up• CMS has published a list of CPT/HCPCS codes that require

modifier -CS for waiver of cost-sharing (Revised 2/11/21) • Physicians and NPP• OPPS• RHCs and FQHCs• CAHs: use OPPS• Method II CAHs: use the OPPS list or the physician and non-physician

practitioner list, as appropriate https://www.cms.gov/files/document/se20011.pdf

https://www.cms.gov/files/zip/cs-modifier-hcpcs-codes-physicians-non-physician-practitioners.zip

https://www.cms.gov/files/document/cs-waiver-opps-codes.pdf

https://www.cms.gov/files/zip/cs-codes-rhc-fqhc.zip



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Resources

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Commercial and Private Payers

• Don’t assume your private payer is following Medicare guidelines

• America's Health Insurance Plans (AHIP)• https://www.ahip.org/issues/coronavirus-covid-19/

• https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

https://www.ahip.org/issues/coronavirus-covid-19/

https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/


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Resources• COVID-19 Blanket Waivers

https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

• Medicare COVID-19 FAQs (updated 1/7/21)https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

• Infographic for Coverage of Monoclonal Antibody Products to Treat COVID-19https://www.cms.gov/files/document/covid-infographic-coverage-monoclonal-antibody-products-treat-covid-19.pdf

• Medicare Part B Payment for COVID-19 Vaccines and Certain Monoclonal Antibodies during the PHEhttps://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies

https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf


https://www.cms.gov/files/document/covid-infographic-coverage-monoclonal-antibody-products-treat-covid-19.pdf

https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies


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Resources• HHS Telehealth Website

https://www.telehealth.hhs.gov/

• Uninsured Patient COVID-19 Claim Reimbursement Claim Systemhttps://coviduninsuredclaim.linkhealth.com/

• Emergency Use Authorizations for Monoclonal Antibody Infusion Products• Bamlanivimab Emergency Use Authorization• Fact Sheet for Healthcare Providers - Emergency Use Authorization of bamlanivimab• Casirivimab and imdevimab Emergency Use Authorization (ZIP)• Fact Sheet for Healthcare Providers - Emergency Use Authorization of casirivimab and imdevimab• Bamlanivimab and etesevimab Emergency Use Authorization• Fact Sheet for Healthcare Providers - Emergency Use Authorization of bamlanivimab and

etesevimab

https://www.telehealth.hhs.gov/

https://coviduninsuredclaim.linkhealth.com/

https://www.fda.gov/media/143602/download

http://pi.lilly.com/eua/bamlanivimab-eua-factsheet-hcp.pdf



http://pi.lilly.com/eua/bam-and-ete-eua-fda-authorization-letter.pdf

http://pi.lilly.com/eua/bam-and-ete-eua-factsheet-hcp.pdf


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