Centers for Medicare & Medicaid Services (CMS) took additional actions to ensure America’s patients, healthcare facilities and clinical laboratories are prepared to respond to the 2019-Novel Coronavirus (COVID-19). On 5th March 2020, CMS has developed a second Healthcare Common Procedure Coding System (HCPCS) code that can be used by laboratories to bill for certain COVID-19 diagnostic tests to help increase testing and track new cases. In addition, CMS released new fact sheets that explain Medicare, Medicaid, Children’s Health Insurance Program, and Individual and Small Group Market Private Insurance coverage for services to help patients prepare as well.
HCPCS is a standardized coding system that Medicare and other health insurers use to submit claims for services provided to patients. In Feb 2020, CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2.
The second HCPCS billing code (U0002) announced allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19). On February 29th, 2020, the Food and Drug Administration (FDA) issued a new, streamlined policy for certain laboratories to develop their own validated COVID-19 diagnostics. This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare or health insurers. CMS expects that having specific codes for these tests will encourage testing and improve tracking.
The Medicare claims processing systems will be able to accept these codes starting on April 1, 2020, for dates of service on or after February 4, 2020. Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates. Laboratories may seek guidance from their MAC on payment for these tests prior to billing for them. As with other laboratory tests, there is generally no beneficiary cost-sharing under Original Medicare.
To ensure the public has clear information on coverage and benefits under CMS programs, the agency also released three fact sheets that cover diagnostic laboratory tests, immunizations and vaccines, telemedicine, drugs, and cost-sharing policies. Medicare Fact Sheet Highlights: In addition to the diagnostic tests described above, Medicare covers all medically necessary hospitalizations, as well as brief “virtual check-ins,” which allows patients and their doctors to connect by phone or video chat.
Medicaid and the Children’s Health Insurance Program (CHIP) Fact Sheet Highlights:
Testing and diagnostic services are commonly covered services, and laboratory and x-ray services are a mandatory benefit covered and reimbursed in all states. States are required to provide both inpatient and outpatient hospital services to beneficiaries. All states provide coverage of hospital care for children and pregnant women enrolled in CHIP. Specific questions on covered benefits should be directed to the respective state Medicaid and CHIP agency.
Individual and Small Group Market Insurance Coverage:
Existing federal rules governing health insurance coverage, including with respect to viral infections, apply to the diagnosis and treatment of Coronavirus (COVID-19). This includes plans purchased through HealthCare.gov. Patients should contact their insurer to determine specific benefits and coverage policies. Benefit and coverage details may vary by state and by the plan. States may choose to work with plans and issuers to determine the coverage and cost-sharing parameters for COVID-19 related diagnoses, treatments, equipment, telehealth and home health services, and other related costs.
“CMS continues to leverage every tool at our disposal in responding to COVID-19,” said CMS Administrator Seema Verma. “Our new code will help encourage doctors and laboratories to use these essential tests for patients who need them. At the same time, we are providing critical information to our 130 million beneficiaries, many of whom are understandably wondering what will be covered when it comes to this virus. CMS will continue to devote every available resource to this effort, as we cooperate with other government agencies to keep the American people safe.”
Local Medicare Administrative Contractors (MACs) will be responsible for establishing the payment amount for claims with the newly created billing codes, CMS added. However, laboratories will able to ask their MACs for guidance on reimbursement for these tests before submitting claims for them. In a separate fact sheet, CMS also highlighted Medicare coverage and payment for services related to COVID-19. The agency stated that, in addition to coronavirus diagnostic tests covered by the new billing codes, traditional Medicare also covers all medically necessary hospitalizations, as well as brief “virtual check-ins” in which providers and patients connect via phone or video chat.