CMS Flexibilities to Fight COVID-19 -COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing

Updated: 5/1/2020

COVID-19 Frequently Asked Questions (FAQs) on

Medicare Fee-for-Service (FFS) Billing

The FAQs in this document supplement the following previously released FAQs: 1135 Waiver FAQs, available at https://www.cms.gov/About-CMS/Agency- Information/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf, and Without 1135 Waiver FAQs, available at https://www.cms.gov/About-CMS/Agency- Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_QsAs.pdf).

We note that in many instances, the general statements of the FAQs referenced above have been superseded by COVID-19-specific legislation, emergency rules, and waivers granted under section 1135 of the Act specifically to address the COVID-19 public health emergency (PHE). The policies set out in this FAQ are effective for the duration of the PHE unless superseded by future legislation.

A few answers in this document explain provisions from the Coronavirus Aid, Relief, and Economic Security (CARES) Act, Public Law No. 116-136 (March 27, 2020). CMS is thoroughly assessing this new legislation and new and revised FAQs will be released as implementation plans are announced.

The interim final rule with comment period (IFC), CMS-1744-IFC, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, is available at the following link: https://www.cms.gov/files/document/covid-final-ifc.pdf

Payment for Specimen Collection for Purposes of COVID-19 Testing

1. Question: What changes did CMS announce regarding specimen collection fees for COVID- 19 testing? Answer: As part of the Public Health Emergency (PHE) for the COVID-19 pandemic and in an effort to be as expansive as possible within the current authorities to have diagnostic testing available to Medicare beneficiaries who need it, in the interim final rule with comment period, we are changing the Medicare payment rules during the PHE for the COVID-19 pandemic to provide payment to independent laboratories for specimen collection from beneficiaries who are homebound or inpatients not in a hospital for COVID- 19 testing under certain circumstances.

New: 4/9/20

2. Question: What has been the Medicare payment policy for specimen collection for laboratory testing and for transportation and personnel expenses for trained personnel to collect specimens from homebound patients and inpatients (not in a hospital)? Answer: In general, the Social Security Act (the Act) requires that the Secretary establish a

Updated: 5/1/2020 pg. 2

Updated: 5/1/2020 pg. 2

nominal fee for specimen collection for laboratory testing and a fee to cover transportation and personnel expenses (generally referred to as a travel allowance) for trained personnel to collect specimens from homebound patients and inpatients (not in a hospital). The travel allowance is paid only when the nominal specimen collection is also payable. Refer to IOM, Pub. 100-04, Chapter 16, Section 60 for more information. For beneficiaries, neither the annual cash deductible nor the 20 percent coinsurance apply to the specimen collection fees or travel allowance for laboratory tests. New: 4/9/20

3. Question: How is the IFC changing the Medicare specimen collection and travel allowance policy? Answer: This IFC is providing a specimen collection fee and fees for transportation and personnel expenses known as a travel allowance for COVID-19 testing under certain circumstances for the duration of the PHE for the COVID-19 pandemic. The IFC also describes the definition of “homebound” for purposes of our specimen collection policy and allowing for electronic records of mileage for the travel allowance for the duration of the PHE for the COVID-19 pandemic. New: 4/9/20

4. Question: Who can bill for the Medicare specimen collection fee? Answer: Independent laboratories can bill Medicare through their MAC for the specimen collection fee. The specimen collection fee applies if the specimen is collected by trained laboratory personnel from a homebound or non-hospital inpatient and the specimen is a type that would not require only the services of a messenger pick up service. However, the specimen collection fee is not available for tests where a patient collects his or her own specimen. New: 4/9/20

5. Question: What is the nominal fee for specimen collection for COVID-19 testing for homebound and non-hospital inpatients during the PHE? Answer: The nominal specimen collection fee for COVID-19 testing for homebound and non-hospital inpatients generally is $23.46 and for individuals in a non-covered stay in a SNF or whose samples are collected by a laboratory on behalf of an HHA is $25.46. Updated: 4/17/20

6. Question: What are the new level II HCPCS codes for specimen collection for COVID-19 testing? Answer: To identify specimen collection for COVID-19 testing, we established two new level II HCPCS codes effective March 1, 2020. Independent laboratories must use one of these HCPCS codes when billing Medicare for the nominal specimen collection fee for COVID-19 testing for the duration of the PHE for the COVID-19 pandemic. These HCPCS codes are:

• G2023, specimen collection for severe acute respiratory syndrome coronavirus 2

Updated: 5/1/2020 pg. 3

Updated: 5/1/2020 pg. 3

(SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source

• G2024, specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source

We note that G2024 is applicable to patients in a non-covered stay in a SNF and not to those residents in Medicare-covered stays (whose bundled lab tests would be covered instead under Part A’s SNF benefit at §1861(h) of the Act). Updated: 4/17/20

7. Question: How should a laboratory document the miles traveled to collect a specimen? Answer: An independent laboratory billing Medicare for the travel allowance is required to log the miles traveled. CMS will not require paper documentation logs that some MACs may have otherwise required; electronic logs can be maintained instead. However, laboratories will need to be able to produce these electronic logs in a form and manner that can be shared with MACs. New: 4/9/20

8. Question: What is the definition of homebound for purposes of our specimen collection policy? Answer: Medicare beneficiaries are considered “confined to the home” (that is, “homebound”) if it is medically contraindicated for the patient to leave the home. When it is medically contraindicated for a patient to leave the home, there exists a normal inability for an individual to leave home and leaving home safely would require a considerable and taxing effort. As an example for the PHE for COVID-19 pandemic, this would apply for those patients: (1) where a physician has determined that it is medically contraindicated for a beneficiary to leave the home because he or she has a confirmed or suspected diagnosis of COVID-19; or (2) where a physician has determined that it is medically contraindicated for a beneficiary to leave the home because the patient has a condition that may make the patient more susceptible to contracting COVID-19. A patient who is exercising “self-quarantine” for his or her own safety during a pandemic outbreak of an infectious disease, such as COVID-19, would not be considered “confined to the home” or “homebound” unless it is also medically contraindicated for the patient to leave the home. If a patient does not have a confirmed or suspected diagnosis of an infectious, pandemic disease such as COVID-19, but the patient’s physician states that it is medically contraindicated for the patient to leave the home because the patient’s condition may make the patient more susceptible to contracting an infectious, pandemic disease, the patient would be considered “confined to the home” or “homebound” for purposes of our specimen collection policy. New: 4/9/20

Updated: 5/1/2020 pg. 4

Updated: 5/1/2020 pg. 4

Diagnostic Laboratory Services

1. Question: How does Medicare pay for clinical diagnostic laboratory tests? Answer: Medicare Part B, which includes a variety of outpatient services, covers medically necessary clinical diagnostic laboratory tests when a doctor or other practitioner orders them. Medically necessary clinical diagnostic laboratory tests are generally not subject to coinsurance or deductible. Posted: 3/6/20

2. Question: Are there Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes available for COVID-19 laboratory testing? Answer: Yes, CMS has created two HCPCS codes in response to the urgent need to bill for these services. The codes are:

• U0001, CDC 2019-nCoV Real-Time RT-PCR Diagnostic Panel and

• U0002, 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC.

Additionally, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel has created CPT code 87635 (Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique) Please visit https://www.ama-assn.org/press-center/press-releases/new-cpt-code-announced-report-novel-coronavirus-test Laboratories can begin billing for the performance of these tests using these codes immediately via standard Fee-for-service billing practices. Revised: 4/10/20

3. Question: Are all of these codes available for laboratories to use to bill Medicare? Answer: Yes. The CMS HCPCS codes will be available on the HCPCS and Clinical Laboratory Fee Schedule (CLFS) file beginning April 1, 2020, for dates of service on or after February 4, 2020. The AMA CPT code, 87635 will also be available on the HCPCS and CLFS file beginning April 1, 2020, for dates of service on or after March 13, 2020. Posted: 3/21/20

4. Question: My laboratory uses the CDC test kit; what code should we use to bill Medicare? Answer: The appropriate code to use would be HCPCS Code U0001 (CDC 2019-nCoV Real-Time RT-PCR) Diagnostic Panel). Posted: 3/21/20

5. Question: My laboratory does not use the CDC test kit; what code should we use to bill Medicare? Answer: If your laboratory uses the method specified by CPT 87635, the appropriate code

Updated: 5/1/2020 pg. 5

Updated: 5/1/2020 pg. 5

to use would be CPT 87635. If your laboratory has a test that uses a method not described by CPT 87635, the appropriate code to use would be HCPCS Code U0002. Posted: 3/21/20

6. Question: What code should we use to bill Medicare if new types of COVID-19 tests are created in the future? Answer: The appropriate code to use would be HCPCS Code U0002 for COVID-19 test methods that are not specified by either U0001 or 87635. CMS will continue to monitor the types of COVID-19 testing methods and adjust coding as necessary depending on the methodology. Posted: 3/21/20

7. Question: How will Medicare pay for COVID-19 testing on the CLFS? Answer: Local MACs are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes and the CPT code in their respective jurisdictions until Medicare establishes national payment rates on the CLFS. Please see https://www.cms.gov/files/document/mac-covid-19-test-pricing.pdf for more information on current MAC payment rates. If there are questions or concerns about payments, laboratories should contact their MAC with additional information. For more information on CMS’s procedures for public consultation on payment for new clinical diagnostic laboratory tests on the CLFS, please see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Laboratory_Public_Meetings. Revised 4/1/20

8. Question: My laboratory does not use the CDC test kit and will have a delay in implementing the CPT code 87635 in our billing system. May we bill Medicare using U0002? Answer: Yes. For the time being laboratories may continue to use U0002 to bill Medicare for tests described by the CPT code. We will provide advance notice if this changes. Posted: 3/21/20

Diagnostic Laboratory Services – Serology Testing

1. Question: Are there new Current Procedural Terminology (CPT) codes for COVID-19 testing? Answer: On April 10, 2020, the American Medical Association (AMA) CPT Committee announced two new CPT codes to report when patients receive blood tests that can detect antibodies for COVID-19. These two codes are:

• 86328: Immunoassay for infectious agent antibody(ies), qualitative or semi-quantitative, single step method (e.g., reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

• 86769: Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Updated: 5/1/2020 pg. 6

Updated: 5/1/2020 pg. 6

New: 5/1/20

2. Question: When will I be able to bill Medicare for these new test codes? Answer: Medicare has updated its billing systems to accept these new test codes. New: 5/1/20

3. Question: My laboratory has a serology test for COVID-19; which CPT code should I use to bill Medicare? Answer: Both new test codes can be used to bill Medicare for COVID-19 serology testing that can detect antibodies. If your COVID-19 test can be done in a single step, the most appropriate code to use is 86328. Multi-step antibody testing for COVID-19 can be billed using 86769. New: 5/1/20

4. Question: What is the difference between single-step and multi-step antibody test for COVID-19? Answer: According to the AMA, CPT code 86328 was established for antibody tests using a single-step method immunoassay. This testing method typically includes a strip with all of the critical components for the assay and is appropriate for a point of care platform. CPT code 86769 was established for COVID-19 antibody tests using a multiple step method. This testing method often involves several steps where a diluted sample is incubated in a sample plate. New: 5/1/20

5. Question: How is the Medicare payment amount determined for the new COVID-19 CPT codes? Answer: Local MACs are responsible for developing the payment amount for claims they receive for these newly created CPT codes in their respective jurisdictions until Medicare establishes national payment rates on the CLFS. Please see https://www.cms.gov/files/document/mac-covid-19-test-pricing.pdf for more information on current MAC payment rates. If there are questions or concerns about payments, laboratories should contact their MAC for additional information. For more information on CMS’s procedures for public consultation on payment for new clinical diagnostic laboratory tests on the CLFS, please see https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ClinicalLabFeeSched/Laboratory_Public_Meetings. New: 5/1/20

6. Question: Can I continue to use HCPCS code U0002 to bill Medicare for COVID-19 testing? Answer: Yes, HCPCS code U0002 is still available for billing Medicare if your test does not fit any of the other existing code descriptors for COVID-19 testing.

New: 5/1/20

Updated: 5/1/2020 pg. 7

Updated: 5/1/2020 pg. 7

High Throughput COVID-19 Testing

1. Question: Why did CMS create HCPCS codes U0003 and U0004? Answer: CMS created two new HCPCS codes, effective for dates of service on or after April 14, 2020, specifically for Clinical Diagnostic Laboratory Tests (CDLTs) making use of high throughput technologies, that is, technologies that use a platform that employs automatically processing of more than 200 specimens a day, as described in CMS Ruling No. CMS-2020-1-R, available at https://www.cms.gov/files/document/cms-2020-01-r.pdf. These new HCPCS codes are:

• U0003: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R

• U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R

New: 5/1/20

2. Question: What will Medicare FFS pay for HCPCS codes U0003 and U0004? Answer: Both codes will be paid at rate of $100. New: 5/1/20

3. Question: Starting when can HCPCS codes U0003 and U0004 be billed to Medicare? Answer: The effective date of CMS Ruling 2020-01-R is April 14, 2020, and the $100 Medicare payment rates for U0003 and U0004 went into effect as of that date. New: 5/1/20

4. Question: My laboratory testing platform is not specifically listed in CMS Ruling CMS-2020-01-R. Can my laboratory bill Medicare for tests run on my platform using U0003 and U0004? Answer: Laboratories may bill Medicare using HCPCS codes U0003 and U0004 when the tests described in those codes make “use of high throughput technologies as described by CMS-2020-01-R.” The Ruling includes a list of examples of high throughput technology as of April 14, 2020, and states that high throughput technologies are not limited to technologies listed in the Ruling. The Ruling states: “A high throughput technology uses a platform that employs automated processing of more than two hundred specimens a day.” Laboratories should ensure that the technologies they are using fulfill this definition when they bill Medicare using these codes and maintain supporting documentation as appropriate. New: 5/1/20

Hospital Services

1. Question: During the COVID-19 PHE, can my hospital provide inpatient services at a site (temporary expansion site) that is not currently part of the hospital or even of another type

Updated: 5/1/2020 pg. 8

Updated: 5/1/2020 pg. 8

of existing healthcare facility? For example, if local hospitals are almost at capacity during the emergency and the few beds remaining must be reserved for patients needing ventilators and critical care, will Medicare pay for non-critical care inpatient services provided directly by the hospital at a temporary expansion site, such as a repurposed school gymnasium or erected tent? Answer: During the COVID-19 PHE, CMS is allowing hospitals to provide inpatient hospital services in temporary expansion sites, which may include ambulatory surgical centers (ASCs), repurposed gymnasiums, erected tents, or other sites, to help address the urgent need to expand their care capacity and to develop COVID-19 specific treatment sites. If a hospital meets the CoPs in effect during the COVID-19 PHE while operating one or more temporary expansion sites, Medicare will pay for covered Medicare inpatient services provided at those sites as if they were provided at the permanent inpatient locations of the hospital. If services were provided by the hospital in another Medicare-participating facility, that facility would not bill Medicare for items and services provided by the hospital. The hospital is expected to be operating in a manner not inconsistent with its state’s emergency preparedness or pandemic plan. New: 5/1/20

2. Question: During the COVID-19 PHE, can my hospital provide outpatient services at a site (temporary expansion site) not considered part of the hospital or even of an existing healthcare facility? For example, if my hospital needs to set up temporary sites for testing or treatment of patients, including those who are COVID-19 positive or suspected to be positive who may need to be isolated, can my hospital provide outpatient services at such a temporary site? Answer: Similar to what CMS is allowing for hospital inpatient services (described above), during the COVID-19 PHE, CMS is allowing hospitals to provide hospital outpatient services in temporary expansion sites, which may include ASCs, gymnasiums or other sites, to help address the urgent need to expand their care capacity. If a hospital meets the CoPs in effect during the COVID-19 PHE while operating one or more temporary expansion sites, Medicare will pay for covered Medicare outpatient services provided at those sites as if they were provided at the permanent outpatient locations of the hospital. The hospital is expected to be operating in a manner not inconsistent with its state’s emergency preparedness or pandemic plan.

Additionally, due to the PHE, CMS is prioritizing and suspending certain Federal and State Survey Agency surveys pursuant to Federal requirements for a period of time. For more information on survey activity see: https://www.cms.gov/files/document/qso-20-20-allpdf.pdf

Updated: 5/1/2020 pg. 9

Updated: 5/1/2020 pg. 9

Revised: 4/17/20

3. Question: Can an acute care hospital repurpose areas of the hospital that are not currently used for patient care (e.g., a cafeteria) as patient care areas, or existing areas that are used for patient care (e.g., outpatient beds) as higher level care areas (e.g., inpatient acute care beds) during the Public Health Emergency? Answer: CMS is providing needed flexibility to hospitals to ensure they have the ability to expand capacity and to treat patients during the COVID-19 PHE. As part of the CMS Hospital Without Walls initiative, for the duration of the COVID-19 PHE, hospitals can repurpose existing clinical (e.g., outpatient beds) and non-clinical space (e.g., cafeterias) for use as acute inpatient patient care areas to help address the urgent need to increase capacity. New: 4/9/20

4. Question: How can Ambulatory Surgical Centers (ASCs) address the needs of patients who may need hospital or ambulatory care during the COVID-19 Pandemic Public Health Emergency? Answer: During the PHE, ASCs may help address the needs in surge areas in several ways. An ASC may furnish inpatient services under arrangement for a hospital, or become provider-based to a hospital, or choose to enroll as a hospital themselves. If an ASC enrolls as a hospital, they must meet the hospital Conditions of Participation, to the extent not waived, and may provide any hospital inpatient or outpatient service provided that it operates in a manner not inconsistent with the State’s emergency preparedness or pandemic plan (for example: COVID-19 treatment site). The ASC would be, functioning as a full hospital, not solely as a hospital outpatient surgical department. Under any of these scenarios, these entities may provide any hospital service as they would be functioning as a hospital rather than an ASC. ASCs that do not provide hospital services under arrangements to an existing hospital or that do not enroll as a hospital themselves may furnish only those services on the ASC Covered Procedures List, and consider the recommendations to delay all elective surgeries as noted in the QSO-20-22 memo: https://www.cms.gov/files/document/qso-20-22-asc-corf-cmhc-opt-rhc-fqhcs.pdf. Any Medicare-certified ASC wishing to enroll as a hospital during the COVID-19 PHE should notify the Medicare Administrative Contractor (MAC) that serves their jurisdiction of its intent by calling the MAC’s provider enrollment hotline and following the instructions noted in the 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs) document. Refer to the QSO-20-24-ASC memo for additional information: https://www.cms.gov/files/document/qso-20-24-asc.pdf. Revised: 4/17/20

5. Question: Do hospitals need to report to CMS or the Medicare Administrative Contractor that they have repurposed an existing area, or worked with an off-site location to create new outpatient or inpatient space?

Updated: 5/1/2020 pg. 10

Updated: 5/1/2020 pg. 10

Answer: No. If the Medicare-approved hospital intends to bill Medicare for the services provided under arrangement, no additional enrollment actions are required. Hospitals may begin billing for care in their surge locations or expansion site for inpatient or outpatient services under their existing CMS Certification Number (CCN) for care furnished during the PHE. CMS will also be exercising our enforcement discretion and will not be conducting the onsite survey for hospital surge locations during the PHE. New: 4/9/20

6. Question: Where can I find the specific waivers to the Medicare Conditions of Participation for acute care and critical access hospitals as well as waivers to the provider-based billing rules? Answer: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf New: 4/9/20

7. Question: Will an ASC that chooses to convert its enrollment to a hospital during the PHE be required to file a Medicare cost report? Answer: For the duration of the PHE, ASCs which rely on blanket waivers issued by CMS to enroll as hospitals during the time period of the PHE will be deemed to have low Medicare program utilization under 42 CFR 413.24(h) and will not be required to submit a full Medicare cost report. These providers will be deemed to satisfy the Medicare cost report submission requirements under 42 CFR 413.24(h) by submitting reduced cost report to their contractors consisting only of a completed and signed certification page from the hospital cost report (Form CMS-2552-10, Worksheet S), signed by the Chief Financial Officer or Administrator. Payments such hospitals receive from the Medicare Inpatient Prospective Payment System or Outpatient Prospective Payment System will be considered as payment in full. Their cost reports will not be used for reconciliation for any additional payments such as disproportionate share, uncompensated care, direct graduate medical education, or Medicare bad debt. Additionally, the cost report data will not be collected and included in the wage index calculations. The Surge Capacity Hospitals’ Medicare cost reports will be due on or before the last day of the fifth month following the close of their fiscal year end, pursuant to § 413.24(f)(2), and electronic filing requirements are waived. New: 4/9/20

8. Question: My ASC participates in Medicare through one of the four CMS-approved ASC accrediting organizations (AO). Do I need to notify the AO of my desire to enroll as a hospital during the COVID-19 PHE? Answer: Notifying your AO is recommended. However, during this PHE and while temporarily operating as a hospital, the facility will fall under the jurisdiction of the State Survey Agency which will coordinate the change in certification to a hospital. As this

Updated: 5/1/2020 pg. 11

Updated: 5/1/2020 pg. 11

situation is temporary, nothing will change with your current AO ASC accreditation. New: 4/9/20

9. Question: How do I make the change from Medicare-certified ASC to enrolling as a hospital? Answer: Interested Medicare-certified ASCs can use the provider enrollment hotline to contact the Medicare Administrative Contractor serving their jurisdiction (information located at: https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf) to enroll as a hospital pursuant to a streamlined enrollment and survey and certification process as long as no Immediate Jeopardy (IJ)-level deficiencies were found within the previous three years for the ASC, or if IJ-level deficiencies were found, they were subsequently removed through the normal survey process, and the relevant location meets the conditions of participation and other requirements not waived by CMS. New: 4/9/20

10. Question: Can an acute care hospital work with another entity to do patient testing offsite, such as in a parking lot? Answer: Yes. Under existing law and regulations, a hospital may elect to furnish hospital outpatient diagnostic tests under arrangements with another entity. The hospital bills Medicare for these services under this scenario. In addition, as mentioned above, the hospital itself may repurpose clinical or non-clinical sites for hospital outpatient or inpatient care under the flexibilities adopted for the duration of the PHE. New: 4/9/20

11. Question: The state government, U.S. Army Corps of Engineers, or other governmental entity established a new care location in our area by repurposing and retrofitting a convention center, gymnasium, tent or other site for patient care. Following its development, our hospital has been brought in to operate and staff this site with our clinicians. Can we bill Medicare for the facility and professional services our organization provides there? If so are there reporting or billing rules that determine how this is done? Answer: Medicare enrolled hospitals that assume the majority operations of a temporary expansion site – including gymnasiums, tents, convention centers, and others – that was built or retrofitted by a public entity can bill Medicare for covered inpatient and outpatient hospital services provided to Medicare beneficiaries at those temporary expansion sites. These temporary expansion sites need to meet the refined hospital conditions of participation. Hospitals would need to follow existing rules to bill under the applicable Medicare payment system depending on whether they provided outpatient care or inpatient care. Hospitals should add the “DR” condition code to inpatient and outpatient claims for patients treated in temporary expansion site during the Public Health Emergency. Similarly, practitioners that furnish covered professional services to Medicare beneficiaries in these temporary expansion sites can bill Medicare for these hospital services.

Updated: 5/1/2020 pg. 12

Updated: 5/1/2020 pg. 12

Practitioners should use the applicable place of service code depending on whether the temporary expansion site is being used to furnish outpatient or inpatient care. Also, practitioners should add the modifier “CR” to professional claims for patients treated in temporary expansion site during the Public Health Emergency. New: 4/9/20

12. Question: Will Medicare provide additional payment if a patient needs to be isolated or quarantined in a private room? Answer: If a Medicare beneficiary is a hospital inpatient for medically necessary care and needs to be isolated or quarantined in a private room, Medicare will pay the Diagnostic Related Group (DRG) rate and any outlier costs for the entire stay until the Medicare patient is discharged. The DRG rate (and outlier payments as applicable) includes payment for when a patient needs to be isolated or quarantined in a private room. There also may be times when beneficiaries may need to be isolated or quarantined in a hospital private room to avoid infecting other individuals. These patients may not meet the need for acute inpatient care any longer, but may remain in the hospital for public health reasons. Hospitals having both private and semiprivate accommodations may not charge the patient a differential for a private room if the private room is medically necessary. Patients who would have been otherwise discharged from the hospital after an inpatient stay, but are instead remaining in the hospital under quarantine, would not have to pay an additional deductible for quarantine in a hospital. New: 4/9/20

13. Question: Can a provider that has both private and semiprivate accommodations charge the patient a differential for a private room where isolation of a beneficiary is required? Answer: A provider with both private and semiprivate accommodations may not charge the patient a differential for a private room if the private room is medically necessary. Posted: 3/6/20

14. Question: Will a hospital be eligible for additional payment for rendering services to patients that remain in the hospital in the case where they continue to need medical care but at less than an acute level and those services are unavailable at any area skilled nursing facilities (SNFs) because of an emergency, including the COVID-19 infection? Answer: A physician may certify or recertify the need for continued hospitalization if the physician finds that the patient could receive proper treatment in a SNF, but no bed is available in a participating SNF. Assuming the original inpatient admission was appropriate for Part A payment, Medicare will pay the DRG rate and any outlier costs for the entire stay until the Medicare patient can be moved to an appropriate facility. Posted: 3/6/20

Updated: 5/1/2020 pg. 13

Updated: 5/1/2020 pg. 13

15. Question: Are hospitals that are paid by Medicare through the Inpatient Prospective Payment System (IPPS) going to be paid using a special payment method during the COVID-19 emergency? Is there a special DRG rate at which IPPS hospitals will be reimbursed for this situation? Answer: There is no special DRG for COVID-19. Recent legislation in the CARES Act provides for increased IPPS payments during the emergency period for Medicare inpatients diagnosed with COVID-19. Further guidance on the implementation of this increased IPPS payment is forthcoming. Otherwise, normal prospective payment methodologies apply to hospitals’ discharges paid under the IPPS rate. Posted: 3/6/20

16. Question: We have a Medicare psychiatric patient requiring inpatient psychiatric care who can’t be placed in the excluded distinct part psychiatric unit because of the COVID-19 emergency. Can we place the psychiatric patient in an acute care hospital bed? Answer: Yes, an acute care hospital with an excluded distinct part psychiatric unit that, as a result of a disaster or emergency, needs to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed can relocate patients. The hospital should continue to bill for inpatient psychiatric services under the Inpatient Psychiatric Facility Prospective Payment System for such patients and annotate the medical record to indicate the patient is a psychiatric inpatient being cared for in an acute care bed because of capacity or other exigent circumstances related to the emergency. This may occur where the hospital’s acute care beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care. For psychiatric patients, this includes assessment of the acute care bed and unit location to ensure those patients at risk of harm to self and others are safely cared for. Revised: 3/26/20

17. Question: Can acute care hospitals use inpatient rehabilitation unit beds to increase bed capacity as a result of the COVID-19 emergency? Answer: Yes, CMS has issued a blanket waiver (https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf) to allow acute care hospitals to house inpatients in their excluded distinct part inpatient rehabilitation facility (IRF) units, where the IRF unit’s beds are appropriate for acute care. The acute care hospital bills for the care under the Inpatient Prospective Payment System and annotates the patient’s medical record to indicate the patient is an acute care inpatient being housed in the excluded unit related to the disaster or emergency. Since these patients would be acute care patients housed in the IRF solely to meet the demands of an emergency, they would not be required to meet the Medicare coverage requirements for IRFs found in 42 CFR 412.622(a)(3), (4), and (5), and guidance in Chapter 1, Section 110 of the Medicare Benefit Policy Manual (Pub. 100-02) and would be excluded from the requirements specified in 42 CFR 412.29(b), which is the regulation commonly

Updated: 5/1/2020 pg. 14

Updated: 5/1/2020 pg. 14

referred to as the “60 percent rule.” New: 3/26/20

Ambulance Services

1. Question: Can ground ambulance providers and suppliers transport beneficiaries with COVID-19 symptoms, or those who are confirmed to have COVID-19, to destination sites that are not a hospital, critical access hospital (CAH) or skilled nursing facility (SNF)? Answer: To provide ground ambulance providers and suppliers the flexibility to furnish medically necessary emergency and non-emergency ambulance transports for beneficiaries during the PHE for the COVID-19 pandemic, we are temporarily expanding the list of allowable destinations for ground ambulance transports. During the COVID-19 PHE, a covered destination for a ground ambulance transport may include any destination that is equipped to treat the condition of the patient in a manner consistent with state and local Emergency Medical Services (EMS) protocols where the services will be furnished. These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, CAH or SNF; community mental health centers; federally qualified health centers; rural health clinics; physician’s offices; urgent care facilities; ambulatory surgical centers; any location furnishing dialysis services outside of the ESRD facility when an ESRD facility is not available; and the beneficiary’s home. There must be a medically necessary ground ambulance transport of a patient in order for the ambulance service to be covered. New: 4/9/20

2. Question: How are Advanced Life Support (ALS) assessment, intervention, and ambulance transport defined? Answer: Definitions for Ambulance Services are in 42 CFR §414.605. ALS assessment, intervention, and ambulance transport are defined as follows:

• Advanced life support (ALS) assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. ALS intervention means a procedure that is, in accordance with State and local laws, required to be furnished by ALS personnel. Advanced life support, level 1 (ALS1) means transportation by ground ambulance vehicle, medically necessary supplies and services and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention.

• Advanced life support, level 2 (ALS2) means either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic

Updated: 5/1/2020 pg. 15

Updated: 5/1/2020 pg. 15

solutions (Dextrose, Normal Saline, Ringer’s Lactate); or transportation, medically necessary supplies and services, and the provision of at least one of the following ALS procedures: (1) Manual defibrillation/cardioversion, (2) Endotracheal intubation, (3) Central venous line, (4) Cardiac pacing, (5) Chest decompression, (6) Surgical airway, and (7) Intraosseous line. New: 4/9/20

3. Question: How is an ALS assessment determined? Answer: Medicare ambulance coverage policy provides that an ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient’s reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. In the case of an appropriately dispatched ALS emergency service if the ALS crew completes an ALS assessment, the services provided by the ambulance transportation service provider or supplier is covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary and all other coverage requirements are met (see Medicare Benefit Policy Manual, Chapter 10, Section 30.1.1.). New: 4/9/20

4. Question: Will all transports of COVID-19 patients or patients suspected to have COVID-19 be designated as Advanced Life Support (ALS) transports? Answer: No. Payment for an ambulance transport is based on the level of service provided. New: 4/9/20

5. Question: Will CMS allow ground ambulance providers and suppliers to treat COVID-19 patients in their home or designated residence and allow for reimbursement at the ALS reimbursement base rate? Answer: Section 1861(s)(7) of the Act describes the ambulance services benefit under Medicare as a transportation benefit, and thus an ambulance transport of a beneficiary is required in order for the ambulance to be paid under Medicare. New: 4/9/20

6. Question: Should HCPCS code A0998 (ambulance response and no transport) be reported for treatment in place? Answer: No, HCPCS code A0998 (ambulance response and no transport) is not covered under the ambulance services benefit (defined in section 1861(s)(7) of the Act), and thus is not payable under Medicare’s Ambulance Fee Schedule. New: 4/9/20

7. Question: Will CMS allow all responses, including Basic Life Support (BLS), related to COVID-19 to be billed at the ALS rate, regardless if ALS interventions were performed?

Updated: 5/1/2020 pg. 16

Updated: 5/1/2020 pg. 16

Answer: We recognize that COVID-19 transports require following infectious disease protocols, such as decontamination procedures, professional protective equipment (PPE), and the required engagement of paramedics which may increase the cost of transports involving suspected or diagnosed COVID-19 patients. However, ground ambulance transports must be billed according to the level of service furnished. Only transports that meet the requirements for billing at the ALS level of service can be billed at the ALS rate. New: 4/9/20

8. Question: Can ground ambulance providers and suppliers report other services they provide to PUI or COVID-19 patients? Answer: Under § 414.610(d), payment under the ambulance fee schedule represents payment in full (subject to applicable Medicare Part B deductible and coinsurance requirements) for all services, supplies, and other costs for an ambulance transport service furnished to a Medicare beneficiary. New: 4/9/20

9. Question: Can I consider any COVID-19 positive patient to meet the medical necessity requirements for ambulance transport? Answer: The medical necessity requirements for coverage of ambulance services have not been changed. For both emergency and non-emergency ambulance transportation, Medicare pays for ground (land and water) and air ambulance transport services only if they are furnished to a Medicare beneficiary whose medical condition is such that other forms of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided for the billed services to be considered medically necessary. New: 4/9/20

10. Question: If the ambulance crew provides treatment but does not transport anyone, can the company bill Medicare for the services provided? Answer: No. Medicare law prohibits payment for an ambulance service unless a medically necessary transport of a Medicare beneficiary has taken place. However, when an enrolled physician or other qualified health professional furnishes services from an ambulance, he or she may bill for those services under the Medicare Physician Fee Schedule, assuming that the services furnished were in accordance with applicable state law and services are within his or her scope of practice requirements. Revised: 3/26/20

11. Question: How will ambulance services be paid when patients are moved from hospital to hospital or other approved locations? Answer: Medicare will pay for ambulance transportation according to the usual payment guidelines. Ambulance transportation charges for patients who were evacuated from and returned to originating hospitals should be included on the inpatient claims submitted by

Updated: 5/1/2020 pg. 17

Updated: 5/1/2020 pg. 17

the originating hospitals. Payment will be included in the diagnostic related group (DRG) payment amounts made to hospitals paid under the prospective payment system. Revised: 3/26/20

12. Question: If a beneficiary who is living at home and using a stationary oxygen unit, has to be transported to another location by ambulance (because other means of transportation are contraindicated), can Medicare pay for any portable oxygen necessary to transport the beneficiary? Answer: Medicare’s standard payment to ambulance providers and suppliers under the Ambulance Fee Schedule for ambulance transports already includes payment for all necessary supplies, including oxygen, provided during the transport. Thus, if the transport is a Medicare-covered service (e.g., the beneficiary must be transported by ambulance to a covered destination because other means of transportation are contraindicated), then no separate payment for furnishing oxygen would be made. However, if the transport does not qualify as a Medicare-covered service, then payment under Part B may be made to a Durable Medical Equipment supplier for furnishing portable oxygen when supplemental oxygen is needed for the beneficiary during the transport. Revised: 3/26/20

13. Question: In emergency/disaster situations, how does CMS define an “approved destination” for ambulance transports and would it include alternate care centers, field hospitals and other facilities set up to provide patient care in response to the emergency/disaster? Answer: CMS defines “approved destination” at 42 CFR 410.40(f), Origin and destination requirements. Medicare can only pay for ambulance transportation when it meets the origin and destination requirements and all other coverage requirements. 42 CFR 410.40(f) allows Medicare to pay for an ambulance transport (provided that transportation by any other means is contraindicated by the patient’s condition and all other Medicare requirements are met) to the following destinations:

• From any point of origin to the nearest hospital, Critical Access Hospital (CAH), or SNF that is capable of furnishing the required level and type of care for the beneficiary’s illness or injury and the return trip to the beneficiary’s home. The hospital or CAH must have available the type of physician or physician specialist needed to treat the beneficiary’s condition.

• For beneficiaries residing in a SNF who are receiving Part B benefits only, ambulance transport from a SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident, including the return trip. For SNF residents receiving Medicare Part A benefits, this type of ambulance service is subject to SNF consolidated billing.

Updated: 5/1/2020 pg. 18

Updated: 5/1/2020 pg. 18

• For a beneficiary who is receiving renal dialysis for treatment of ESRD, from a beneficiary’s home to the nearest facility that furnishes renal dialysis, including the return trip.

A physician’s office normally is not a covered destination under Medicare Part B. However, under certain circumstances an ambulance transport may temporarily stop at a physician’s office without affecting the coverage status of the transport. Note that there is an exception to this rule during the COVID-19 PHE, as explained further below. Should a facility that would normally be the nearest appropriate facility be unavailable during an emergency/disaster, Medicare may pay for transportation to another facility so long as that facility meets all Medicare requirements and is still the nearest facility that is available and equipped to provide the needed care for the illness or injury involved. Medicare payment for an ambulance transport to a temporary expansion site may be available if the site is determined to be part of a hospital, CAH or SNF that is an approved destination for an ambulance transport under 42 CFR 410.40(f). If the temporary expansion site is part of a hospital, CAH or SNF that is an approved destination under 42 CFR 410.40(f) for an ambulance transport, Medicare will pay for the transport on the same basis as it would to any other approved destination. In addition, to provide ground ambulance providers and suppliers the flexibility to furnish medically necessary emergency and non-emergency ambulance transports for beneficiaries during the PHE for the COVID-19 pandemic, we are temporarily expanding the list of allowable destinations for ground ambulance transports. During the COVID-19 PHE, a covered destination for a ground ambulance transport may include any destination that is equipped to treat the condition of the patient in a manner consistent with state and local Emergency Medical Services (EMS) protocols in use where the services will be furnished. These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, CAH or SNF; community mental health centers; federally qualified health centers; rural health clinics, physician’s offices; urgent care facilities; ambulatory surgical centers; any location furnishing dialysis services outside of the ESRD facility when an ESRD facility is not available; and the beneficiary’s home. There must be a medically necessary ground ambulance transport of a patient in order for the ambulance service to be covered. Physicians, non-physician practitioners, and suppliers should contact their Part B MAC or DME MAC with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS Medicare Learning Network (MLN) Publications webpage.

Updated: 5/1/2020 pg. 19

Updated: 5/1/2020 pg. 19

Institutional providers should contact their Part A MAC with questions about SNF consolidated billing. There is also additional information about SNF consolidated billing on the CMS MLN Publications webpage. Revised: 4/10/20

14. Question: Our ambulance uses an electronic patient care reporting device to record beneficiary signatures that authorize submission of claims to Medicare. We are concerned that a known or suspected COVID-19 patient using a touch screen to sign or holding an electronic pen or stylus could contaminate these devices for future patients and for ambulance personnel. Are we permitted to sign on behalf of a patient with known or suspected COVID-19? Answer: Yes, but only under specific, limited circumstances. CMS will accept the signature of the ambulance provider’s or supplier’s transport staff if that beneficiary or an authorized representative gives verbal consent. CMS has determined that there is good cause to accept transport staff signatures under these circumstances. See 42 CFR 424.36(e). CMS recommends that ambulance providers and suppliers follow the Centers for Disease Control’s Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States, which can be found at the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html. This guidance includes general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with known or suspected COVID-19. However, in cases where it would not be possible or practical (such as a difficult to clean surface) to disinfect the electronic device after being touched by a beneficiary with known or suspected COVID-19, documentation should note the verbal consent. New: 4/10/20

Ambulance Services- Vehicle and Staffing Requirements for Ambulance Providers and Suppliers

1. Question: Would a ground ambulance vehicle operating without a renewed license nevertheless satisfy the Medicare requirements at 42 CFR § 410.41 if, during the PHE for the COVID-19 pandemic, a state or locality issues a law or regulation, or a legally adequate waiver, that permits ground ambulance vehicles to operate without a renewed license? Answer: Yes, depending on state or local law. 42 CFR § 410.41 specifies Medicare’s requirements for ambulance vehicles, and § 410.41(a)(1) states that a vehicle used as an ambulance must be specially designed to respond to medical emergencies or provide acute medical care to transport the sick and injured and comply with all State and local laws governing an emergency transportation vehicle. Key to this is that § 410.41(a) requires compliance with state and local laws. During the PHE for the COVID-19 pandemic, should a state or locality enact or promulgate a law, regulation, or legally adequate waiver permitting an ambulance vehicle to operate without a renewed license, such an ambulance would be in compliance with Medicare’s requirements at § 410.41(a). We also note that the

Updated: 5/1/2020 pg. 20

Updated: 5/1/2020 pg. 20

staffing requirements at § 410.41(b) must be met in order for the ambulance transport to meet the § 410.41 requirements (see discussion in the FAQs below regarding waivers of these provisions). New: 5/1/20

2. Question: During the PHE for the COVID-19 pandemic, if a state law or local law permits ambulance staffing by personnel licensed/certified below the levels of certification required under 42 CFR § 410.41(b), would an ambulance so staffed be considered to meet the Medicare requirements of § 410.41(b)? For example, CMS has heard that, during the course of the PHE for the COVID-19 pandemic, and pursuant to state waiver, one or more states may permit an Emergency Medical Responder (EMR), which is a certification status below the scope of practice of an Emergency Medical Technician (EMT) to staff a Basic Life Support (BLS) vehicle, or a Registered Nurse (RN), which is a health care professional status different than an EMT-paramedic, to staff an Advanced Life Support (ALS) vehicle. Answer: Yes, depending on state or local law. During the PHE for the COVID-19 pandemic, and pursuant to 42 U.S.C. 1320b-5(b)(1)(B), Medicare is waiving the specified ambulance staffing certification requirements of 42 CFR § 410.41(b) such that, if a state and/or local law, or regulation, or a waiver issued by the applicable state or local authority permits a BLS or ALS ambulance to be alternatively staffed, such staffing arrangement would satisfy Medicare requirements. For example, should it be permitted by a state or local law, or regulation, or a waiver issued by the applicable state or local authority, for purposes of meeting Medicare’s staffing requirements for a covered transport, a BLS vehicle could be staffed with an EMR instead of an EMT-basic or an ALS vehicle could be staffed with an RN instead of a EMT or paramedic. Note that the onus is on an ambulance provider or supplier to ensure that it otherwise continues to meet all applicable Medicare enrollment, coverage, and other requirements. New: 5/1/20

3. Question: During the PHE for the COVID-19 pandemic, if an ambulance provides services across state lines and the vehicle staff are not licensed or certified to provide services in the state in which the ambulance services are provided, will the ambulance be considered to meet the vehicle staff certification requirements under 42 CFR § 410.41(b) while providing services in that state? Answer: During the PHE for the COVID-19 pandemic, pursuant to 42 U.S.C. 1320b-5(b)(2), Medicare is waiving the requirement at 42 CFR § 410.41(b) that vehicle personnel be licensed or certified in the State in which they are furnishing services if they have equivalent licensing or certification in another State and are not affirmatively excluded from practice in that State or in any other State. Where the terms of this waiver are met, the ambulance staff certification requirements of § 410.41(b) could be met when ambulances provide services across state lines. Note, however, that this does not waive state or local laws (only Medicare’s own certification requirements in § 410.41(b) for purposes of Medicare payment and coverage) such that, should a state not permit out of state ambulances to

Updated: 5/1/2020 pg. 21

Updated: 5/1/2020 pg. 21

provide services, Medicare’s waiver would not affect a state’s potential enforcement of its provisions. New: 5/1/20

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

1. Question: Has CMS implemented any changes to help RHCs and FQHCs respond to the to the serious public health threats posed by the spread of the 2019 novel coronavirus (COVID-19)? Answer: Yes. CMS has removed some regulatory requirements and added additional flexibilities to assist RHCs and FQHCs in furnishing services during the COVID-19 Public Health Emergency (PHE). These include:

a) Expansion of Virtual Communication Services for RHCs and FQHCs to include online digital evaluation and management services using patient portals; and

b) Revision of Home Health Agency Shortage Area Requirement for Visiting Nursing Services Furnished by RHCs and FQHCs

New: 4/9/20

2. Question: When do these changes go into effect? Answer: These changes are in effect for the duration of the COVID-19 PHE and are not permanent. New: 4/9/20

3. Question: Are these changes permanent? Answer: These changes are in effect for the duration of the PHE for the COVID-19 pandemic and are not permanent. New: 4/9/20

4. Question: Do these changes apply to all RHCs and FQHCs? Answer: Yes. They apply to all RHCs (independent/freestanding and provider-based) and all FQHCs (including grandfathered tribal FQHCs). New: 4/9/20

Expansion of Virtual Communication Services for FQHCs/RHCs

1. Question: What are “online digital evaluation and management services” in RHCs and FQHCs? Answer: Online digital evaluation and management services are non-face-to face, patient-initiated, digital communications using a patient portal, that require a clinical decision that otherwise typically would have been provided in the office. CMS has been paying separately under the physician fee schedule for these services since before the PHE and is expanding the same flexibilities to RHCs and FQHCs.

Updated: 5/1/2020 pg. 22

Updated: 5/1/2020 pg. 22

New: 4/9/20

2. Question: Are there specific codes that describe these services? Answer: Yes. The codes that have been added for RHCs and FQHCs are:

• 99421 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

• 99422 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

• 99423 – Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes. New: 4/9/20

3. Question: What is an online patient portal? Answer: An online patient portal is a secure online website that gives patients 24-hour access to personal health information from anywhere with an Internet connection by using a secure username and password. New: 4/9/20

4. Questions: Does the RHC or FQHC practitioner have to be physically in the RHC or FQHC, or can they respond from another location such as their home? Answer: The RHC or FQHC practitioner can respond from any location during a time that they are scheduled to work for the RHC or FQHC. New: 4/9/20

5. Question: How will Medicare pay RHCs and FQHCs for performing online digital evaluation and management services? Answer: The online digital assessment codes are being added to the codes that are billed using HCPCS code G0071, the RHC/FQHC specific code for Virtual Communication Services. New: 4/9/20

6. Question: How can RHCs and FQHCs bill for online digital evaluation and management services? Answer: RHCs and FQHCs can bill for online digital evaluation and management services using the RHC/FQHC HCPCS code G0071. The payment for G0071 will be the PFS national non-facility payment rate for HCPCS code G2012 (communication technology-based services), HCPCS code G2010 (remote evaluation services), CPT 99421, CPT 99422, and CPT 99423. The new payment rate is $24.76. New: 4/9/20

7. Question: When will the new payment rate for G0071 be effective? Answer: The new payment rate is effective for services provided on or after March 1, 2020. However, claims submitted with this code before the claims processing system is updated will be reprocessed.

Updated: 5/1/2020 pg. 23

Updated: 5/1/2020 pg. 23

New: 4/9/20

8. Question: How frequently can G0071 be billed by RHCs and FQHCs? Answer: Because these codes are for a minimum 7-day period of time, they cannot be billed more than once every 7 days. New: 4/9/20

9. Question: Can virtual communication services be furnished to both new and established patients? Answer: Yes. Virtual communication services may be furnished to both new and established patients during the COVID-19 PHE. New: 4/9/20

10. Question: Is beneficiary consent required? Answer: Yes, but during the PHE, it may be obtained at the same time the services are furnished. New: 4/9/20

Revision of the Home Health Agency Shortage Area Requirement for Visiting Nursing Services Furnished by RHCs and FQHCs

1. Question: Can RHCs and FQHCs bill for visiting nursing services? Answer: Yes. In an area in which there exists a shortage of home health agencies (HHAs), visiting nursing services can be furnished to a homebound individual by an RN or a LPN under a written plan of treatment. New: 4/9/20

2. Question: How are we changing the HHA shortage area requirement for visiting nursing services and what additional flexibilities does this provide for RHCs and FQHCs? Answer: During the COVID-19 PHE, we will assume that the area typically served by the RHC, and the area that is included in the FQHC’s service area plan, has a shortage of home health agencies, and no request for this determination is required. The RHC or FQHCs must check the HIPAA Eligibility Transaction System (HETS) before providing visiting nurse services to ensure that the patient is not already under a home health plan of care. No visits will be payable to the RHC/FQHC if such patient is already being treated under a home health plan of care. New: 4/9/20

3. Question: Is there a change in how “homebound” is determined? Answer: No. During the PHE, as previously, a patient would be considered “homebound” if it is medically contraindicated for the patient to leave the home. The patient’s medical records must document leaving the home is medically contraindicated. For example, a beneficiary could be considered “homebound” if: (1) a physician has determined that it is

Updated: 5/1/2020 pg. 24

Updated: 5/1/2020 pg. 24

medically contraindicated for a beneficiary to leave the home because he or she has a confirmed or suspected diagnosis of COVID-19; or (2) where a physician has determined that it is medically contraindicated for a beneficiary to leave the home because the patient has a condition that may make the patient more susceptible to contracting COVID-19. New: 4/9/20

4. Question: Can a visiting nurse service be billed if the nurse goes to the patient’s home to collect a lab specimen for coronavirus testing? Answer: Not if it is the only service provided. Visiting nurse services are only billable as an RHC/FQHC visit when they require skilled nursing services. If the RN or LPN collects a specimen for testing and does not provide skilled nursing services under a written plan of treatment, then it would not be a RHC or FQHC billable visit. New: 4/9/20

5. Question: How does this change affect how RHCs and FQHCs bill for visiting nursing services? Answer: There are no billing changes for visiting nursing services. Qualified visiting nursing services are billed as an RHC or FQHC visit using revenue code 0527. New: 4/9/20

Medicare Telehealth (Please note that these FAQs do not include flexibilities that might be exercised under the CARES act)

1. Question: What services can be provided by telehealth during a waiver for the public health emergency (PHE) declared by the Secretary under the section 1135 waiver authority? Answer: Medicare telehealth services include many services that are normally furnished in-person. CMS maintains a list of services that may be furnished via Medicare telehealth. This list is available here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes. These services are described by HCPCS codes and paid under the Physician Fee Schedule. Under the emergency declaration and waivers, these services may be provided to patients by physicians and certain non-physician practitioners regardless of the patient’s location. Medicare also pays for certain other services that are commonly furnished remotely using telecommunications technology, but are not considered Medicare telehealth services. These services can always be provided to patients wherever they are located, and include physician interpretation of diagnostic tests, care management services, and virtual check-ins. New: 4/9/20

2. Question: Who are the Qualified Providers who are permitted to furnish telehealth services under the PHE waiver? Answer: The same health care providers are still permitted to furnish Medicare telehealth services under the waiver authority during the Public Health Emergency, including

Updated: 5/1/2020 pg. 25

Updated: 5/1/2020 pg. 25

physicians and certain non-physician practitioners such as nurse practitioners, physician assistants and certified nurse midwives. Other practitioners, such as certified nurse anesthetists, licensed clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals may also furnish telehealth services within their scope of practice and consistent with Medicare benefit rules that apply to all services. New: 4/9/20

3. Question: Is any specialized equipment needed to furnish Medicare telehealth services? Answer: Currently, CMS allows telehealth services to be furnished using telecommunications technology that has audio and video capabilities that are used for two-way, real-time interactive communication. For example, to the extent that many mobile computing devices have audio and video capabilities that may be used for two-way, real-time interactive communication, they qualify as acceptable technology. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html. New: 4/9/20

4. Question: Can practitioners provide Medicare telehealth services using their phones? Answer: Yes, for use of certain phones. Section 1135(b)(8) of the Social Security Act allows the Secretary to authorize use of telephones that have audio and video capabilities for the furnishing of Medicare telehealth services during the COVID-19 PHE. Additionally, CMS amended its regulations through the IFC to remove the potential perception of restrictions on technology that practitioners can use to provide telehealth services. The Office of Civil Rights has also issued guidance allowing covered health care providers to use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype, to provide telehealth without risk of penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html. New: 4/9/20

5. Question: How does a health care provider bill for telehealth services? Answer: The IFC directs physicians and practitioners who bill for Medicare telehealth services to report the place of service (POS) code that would have been reported had the service been furnished in person. This will allow our systems to make appropriate payment for services furnished via Medicare telehealth which, if not for the PHE for the COVID-19 pandemic, would have been furnished in person, at the same rate they would have been paid if the services were furnished in person. We believe this interim change will maintain overall relativity under the PFS for similar services and eliminate potential financial deterrents to the clinically appropriate use of telehealth. During the PHE, the CPT telehealth modifier, modifier 95, should be applied to claim lines that describe services

Updated: 5/1/2020 pg. 26

Updated: 5/1/2020 pg. 26

furnished via telehealth. Practitioners should continue to bill these services using the CMS-1500/837P. New: 4/9/20

6. Question: How much does Medicare pay for telehealth services? Answer: Medicare pays the same amount for telehealth services as it would if the service were furnished in person. New: 4/9/20

7. Question: How long will practitioners be able to bill using these new flexibilities? Answer: The telehealth waiver will be effective until the end of the PHE declared by the Secretary of HHS on January 31, 2020. Billing for the expanded Medicare telehealth services, as well as for the telephone assessment and management, telephone, evaluation and management services, and additional flexibilities for communications technology-based services (CTBS) are effective beginning March 1, 2020, and through the end of the PHE. New: 4/9/20

8. Question: Can physicians and practitioners let their patients know that Medicare covers telehealth in new locations during the PHE? Answer: Yes. Physicians and practitioners should inform their patients that services are available via telehealth in new locations, including their homes, during the PHE and educate them on any applicable cost sharing. New: 4/9/20

9. Question: Should on-site visits conducted via video or through a window in the clinic suite be reported as telehealth services? How could a physician or practitioner bill if this were telehealth? Answer: Services should only be reported as telehealth services when the individual physician or practitioner furnishing the service is not at the same location as the beneficiary. If the physician or practitioner furnished the service from a place other than where the beneficiary is located (a “distant site”), they should report those services as telehealth services. If the beneficiary and the physician or practitioner furnishing the service are in the same institutional setting but are utilizing telecommunications technology to furnish the service due to exposure risks, the practitioner would not need to report this service as telehealth and should instead report whatever code described the in-person service furnished. New: 4/9/20

10. Question: How are telehealth services different from virtual check-ins and e-visits? How much does Medicare pay for these services? Answer: Medicare telehealth services are services that would normally occur in person but are instead conducted via telecommunications technology and are paid at the full in-

Updated: 5/1/2020 pg. 27

Updated: 5/1/2020 pg. 27

person rate. Service such as the virtual check-in, eVisits, remote evaluation, and telephone visits are not services that would normally occur in person, and are not paid as though the service occurred in person. A virtual check-in lets professionals bill for brief (5-10 min) communications that mitigate the need for an in-person visit and can be furnished via any synchronous telecommunications technology visit that would be furnished along with an e-visit is similar to a virtual check-in, but should be reported when a beneficiary communicates with their health care provider through an online patient portal. Telephone visits may be furnished via audio-only telephone whereas the remote evaluation describes the evaluation of a prerecorded video or image provided by the patient. Table 1 illustrates the respective payment rates to the physician or other practitioner; they vary based on the practice setting. New: 4/9/20