Federal regulatory updates continue to be issued regularly to unburden our strained healthcare system while combatting COVID-19. CMS maintains regular Q&A sessions to deliver guidance to providers seeking clarity on all COVID-19 related matters. Regulatory changes range from blanket waivers and telehealth, to coding, billing and testing; and Advis remains committed to remaining abreast of all updates. We stand ready to provide answers to imperative questions.
Advis has developed a categorized compilation of top COVID-19 questions provided in CMS Office Hours sessions. We will continually update these questions as additional sessions are organized:
Telehealth
Question: If PT/OT/SLP are credentialed through CMS, can they bill on 1500 for services via telehealth, virtual e-visit, e-visit, or telephone calls? Should they do ABN to advise clients, and can they do that over the phone?
Answer: At the moment, therapists are not able to furnish telehealth. E-visits can be reported as well as virtual check-ins as long as they’re employees of the hospital and hospital billing rules, which still apply, are followed. ABN’s are not allowed to be delivered by telephone.
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Question: Hospitals have been waiting on regulations for 2 weeks, and CMS was asked to please consider rural locations. Is there a way to build in telephone/telehealth type reimbursement?
CMS: CMS is actively working on this and hopes to release something shortly. Statutory provision allows RHCs to furnish telehealth services; they will develop a payment system, which is in the works. Audio-only is also under advisement. Interim final rule reimbursement for virtual code has been increased and services can be done audio only.
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Question: Can you clarify if both initial and required comprehensive assessments for Hospice can be done via telehealth? Providers have previously been instructed to not put these types of visits on claims. Can MACs process a claim with no in-person visits? Does this apply to Home Health as well?
Answer: As long as you are putting level of care on the claim, and a Q code, the claim should pay even without a G code. There is nothing in COPs of either provider type for how assessments are performed. So, there is nothing that prohibits it from being done. They do require that a comprehensive view of the patient’s status be provided. To the extent telehealth can be used to accomplish this, yes, it can be done. If in-person is needed, then that will need to be done
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Question: If a physician is doing telemedicine from their home and the patient is at their home, the physician puts home address on Box 32 and does not need to update enrollment, correct?
Answer: That visit would have ordinarily taken place in a practice location, so the practice location would also be correct. No update needed to enrollment.
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Question: For Hospital billing for telehealth, physician is to use Place of Service where it would have been provided. Under this regulation, can the hospital bill its portion of the E/M for telehealth visit?
Answer: Under current rules, telehealth is only billable for the furnisher of services. CMS is looking at how the existing rules work in context of current environment.
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Question: Code Q3014 is generally only used on UBs. Providers are putting on 1500. Some professionals are within the hospital and are utilizing hospital staff, equipment, etc. Provider is on site at the hospital and patient at home. How do they bill in this situation?
Answer: When service is happening within same location, it is not considered telehealth and not subject to restrictions. But this circumstance is part of a broader set of considerations and CMS is actively looking at this. If patient and practitioner are both in the institutional setting, then telehealth wouldn’t be limited to provider only.
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Question: Face to face visits must be audiovisual. What if the patient only has a land line? Should Hospices submit an individual waiver request for those patients needing to be recertified?
Answer: This request cannot be granted under a waiver because it is a statutory requirement that would require a policy change.
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Question: For telehealth services, should they be billing with a 95 modifier? Today, a non-CMS article indicated they should be using CF modifier to receive facility over non-facility reimbursement.
Answer: For all telehealth services during emergency, use a 95 modifier with Place of Service code where the service would have been provided had telehealth not been needed. Article may have been incorrect.
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Question: Can CMS address telehealth questions regarding PT/OT/ST? We have heard they have been excluded from reimbursement under telehealth.
Answer: CMS is aware of the question and understands its significance. CMS is actively looking at changes that can be made on their usual authority and via new authorities granted through the CARES Act. Remain optimistic that changes can happen, but currently there is no mechanism for billing under intuitional claim.
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Question: Will CMS pay for audio only visits?
Answer: CMS continues to review this and has heard a lot of questions about audio only. Presently, the codes for telephone E/M visits are paid under physician specific CPT codes. For the remainder of telehealth, both audio and visual must be used.
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Question: Under normal therapy, PT/OT can bill for ‘incident to’ with the physician’s NPI. Can PT/OT do a telehealth visit right now ‘incident to’ under a physician NPI, or still no?
Answer: Under current policy, the answer is no. They are actively looking at authority. They added a new number of therapy services to telehealth list, and anticipate issuing guidance in the near future.
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Question: Will changes for PT/OT regarding telehealth be retroactive, and can they start doing telehealth, and then go back and bill for this?
Answer: They have been retroactive in many other cases, and may be willing to act in that way.
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Question: Implored CMS to look at telehealth for non- physician practitioners such as registered dieticians, social workers, etc., where they are in hospital an outpatient department with both audio-visual interaction with the patient off site. Reimbursement on UB not allowed.
Answer: They are exploring this and understand the importance of the issue.
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Question: Are they paying attention to 7-day E/M rule related to bundling rules for virtual services?
Answer: None of the rules have been changed relative to bundling rules for virtual services so they would continue to apply. They would continue to be bundled.
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Question: Under 1744 interim final rule related to supervision of “incident to” services for NP and PA, physician has the allowance to choose which communication methods are appropriate. Does that mean it is okay to use telecommunication, or do they have to have their phone on with the physician on the screen, or just readily available to help?
Answer: Change in policy is to allow the virtual presence to take the place of in person presence. Therefore, readily available would apply.
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Question: Under guidance telehealth should be billed at the place of service it normally would be held. For hospital-based providers, they can bill a Place of Service 19 or 22. Should they be billing a Place of Service 11 like a private physician would be?
Answer: No. The policy is intended to maintain the payments to the physician the same as if it were in person.
Question: What code should be used for a physician office or Urgent Care to be paid for specimen collection for COVID test?
Answer: There is no specific code for specimen collection (swab). Bill the most appropriate code for swab testing. May be bundled or packaged into service.
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Question: Specimen collection at Urgent care sites. G2023 is HCPCS code for any specimen for COVID 2 respiratory collection – can they use that for COVID-19 swab test? This is occurring in the hospital setting and nurses (not lab technicians) are doing this.
Answer: When they finalized the rules, this code was parallel to an existing policy for specimen collection. They will take question back. Typically, these are collected regardless of how or where they are managing infection control and have not necessarily been paid separately for it. G2023 is not typically used in the hospital setting.
Question: There is a physician in a neighboring state coming to work in the ED. How should that be billed when a physician covers ED in a neighboring state?
Answer: No particular billing requirement for the out of state issue. Advised to review waivers that do not require licensure.
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Question: If a patient is in observation status in a hospital and needs to come to a SNF, will CMS waive 3-day qualifying stay requirement?
Answer: Yes. This was done under a waiver under1812(f) authority.
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Question: Will the 50 bed rule be waived during the emergency under hospitals without walls?
Answer: This has not yet been resolved, but CMS is working on it.
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Question: If a SNF chooses to use 1135 waiver for eliminating the 3-day qualifying hospital stay, what sort of documentation is required? Something from the hospital stating that they couldn’t take them?
Answer: Regarding 1135 question – this is a blanket waiver. There is no action needed to further waive this action.
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Question: Hospitals can transfer patients outside of their walls, such as into a hotel, and receive reimbursement. Assuming the same services are provided in a patient home, can the program be used to expand capacity into the patient’s home with the same recognition by CMS for payment under the IPPS?
Answer: Under Hospital without Walls, the alternative site is essentially serving as a hospital site. If the home is serving as a hospital site, that site would have to meet all requirements that are not waived.
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Question: Under 1135 waiver for SNF as it relates to adding a second benefit period, if the SNF has a resident who has exhausted their benefits, is any break needed, or would next day be 101 or start at day 1 again? In second benefit period, are the first 20 days covered or is a co-payment required?
Answer: Answer 1812(f) waiver is intended to help patients be in the hospital for as short a time as possible. Purpose is to assist with creating surge capacity in getting beneficiaries to skilled facilities quickly. If the patient has continued skilled care need, unrelated to COVID emergency, beneficiary cannot renew benefits under 1812(f) waiver. This waiver was designed primarily to eliminate the 3-day qualifying hospital stay.
Question: Can a PTA and COTA provide an e-visit and telephone service under the NPI of a therapist? Can a PT/OT bill on UB04 claim?
Answer: Codes are for the individual who is billing for those services so, no, to the first question. Services of a PT/OT are generally reported on a professional claim. For those typically reported on hospital claims, however, how they would normally be paid would apply to that situation.
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Question: For outpatient E/M codes 99201-99215, we can use 2021 guidelines for determining level. Where do we find guidelines for time? AMA CPT or does CMS have their own list of times?
Answer: Times are available in code descriptors themselves. They are also with each CPT code in file on physician fee schedule on cms.gov website. CMS will reiterate this in a future communication.
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Question: Requested clarification on CF modifier. Particular to outpatient and seems to be applied to E/M code. Is this accurate?
Answer: CF modifier, which waives cost sharing for E/M services, should be used when one of the E/M services is billed. They can be found in CPT codebook. If a practitioner, place the modifier at the line level.
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Question: In FAQ, it says to use CR and condition code DR. Do they put CF and CR since CR is mandatory? On UB04 is where they need clarification.
Answer: For CR and DR, it says its related to emergency. For telehealth, they do not need to have CR or DR, but in every other situation they do. This is in addition to CF where it is applicable. They will put out further guidance.
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Question: Is DR modifier used only when a waiver is used? Please clarify. Also clarify when the CR is used?
Answer: For Medicare, they are used with waivers; not everything else.
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Question: Regarding codes G2061-G2063. Can it be billed more than once in the same episode of care given that an episode could be many months long?
Answer: No restriction over a long episode of care
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Question: Can e-visits and virtual check-ins be billed on a UB?
Answer: As a general rule, most of the codes for those services are really professional services, and would not be paid to the institution themselves.
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Question: G2023 follow-up question. Any more consideration to hospitals being able to bill for this? Holding thousands of claims, specifically regarding G2023.
Answer: Code is not currently payable for hospital outpatient department. Actively considering this. They should have guidance very soon regarding G2023.
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Question: Cannot bill for services unless physician resident documentation is co-signed. The hospital is experiencing difficulty with getting everything signed by physicians. Will they make any concessions for this?
Answer: CMS will look into this further and provide a response.
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Question: Regarding CF modifier being outpatient only. If patient is an inpatient and provider does an E/M service, does that mean you cannot append with CF modifier?
Answer: In hospital setting, it only applies to outpatient.
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Question: Regarding Hospital without Walls billing.
Answer: CMS is working to address billing when patients are not at a hospital setting.
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Question: CF modifier would be appended to E/M which resulted in COVID test. Should also be appended if COVID test is not needed?
Answer: Statute indicates that a test is required for that modifier to apply.
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Question: Follow-up question related to COVID test required to be on the claim for the cost sharing not to be attributed. What if they did test on one visit and not the second visit and the test is not on the same claim How do they handle this?
Answer: The statue requires that the test be ordered. It does not go as far as to say the test must be on the claim. They will look at this further. Cost sharing waiver does not apply to IP; it is specific to OP setting.
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Question: If an RHC provides a service that is subject to waivers, do you use DR modifier on the UB04 and a CR modifier on the professional claim?
Answer: Yes.
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Question: Under E/M services, critical care codes were not included in the listing of services that result in a COVID test. Should it have been included to have the CF modifier? Critical care is listed as its own category, so requesting clarification.
Answer: CMS was uncertain of response and will take question back.
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Question: Any there any frequency limitations with visits that result in COVID-19 testing?
Answer: They do not believe there are any policy limits as long as, in both cases, they were medically reasonable.
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Question: If laboratory specimens are collected in an outside specimen collection station, but run in the inside lab, can they use 99211 if they put place of service 15?
Answer: Can use that code for specimen collection as long as you are meeting the requirements.
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Question: Is CPT 86769 reimbursable? Has the reimbursement rate been established?
Answer: CPT Code 8769 has not been added to the hospital list at this time. It is under review.
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Question: If you are on a call for 45 minutes, during a single call, do you bill one unit of 98967 and 98968? There is no code for >30 minutes.
Answer: As a general rule, you aggregate minutes together. They need to take this back for review. Safest way to do it is use 98968 (21-30 minutes).
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Question: For telehealth services, if two calls are needed on the same day by the same provider, can they add times together for one code?
Answer: All services are aggregated for reporting.
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Question: For office E/M codes, are they required to adopt 2021 codes, or can they use those already programmed into their EHR (i.e. 2020 guidelines).
Answer: You can still use 2020 guidelines. You are not required to use 2021.
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Question: Code G2023 is for independent laboratories. Is CMS looking to lift the restrictions so that this will also apply to hospitals?
Answer: Yes – CMS is definitely looking into this.
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Question: Can they bill 99441-99443 if they are in a nursing home and don’t have access to video?
Answer: Under current rules, telephone E/M codes would be appropriate to use for audio only.
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Question: Clarification was requested that they only apply CR modifier for 0001-0004.
Answer: Use CR modifier any time you use a waiver. This also applies to DR modifier. If you believe it is related to a waiver, CMS recommends you put it on a claim. Do not use CF on cost sharing because there is no co-payment.
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Question: Does the CF modifier apply to 121 bill type?
Answer: This is rarely used, but to the extent you are furnishing CPT codes on a 121x bill, but still considered for CF modifier, they think it is fine, but will have to take it back for review.
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Question: Regarding $100 for high speed test. There is no mention as to what specific tests this applies to. Is there a list of what qualifies?
Answer: They created two new U codes (U003 and U004) which provide an explanation with examples. There is not a comprehensive listing, but definitive criteria.
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Question: Under use of CF modifier, non-OPPS or Maryland hospitals are not listed. Was this an omission?
Answer: The guidance ties right back to the law, but the statute doesn’t specify. CMS will have to take this question back and review.
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Question: CF modifier is to be used on outpatient claims where share of costs has been waived, correct? Would this also apply to a CXR to determine if a COVID test ends up being ordered? There is conflicting guidance, as the coding guidance says CF modifiers go only on E/M, but the law says the visit and any test.
Answer: The law requires this if the testing related service in any category is furnished during emergency and results in an order or administration of a clinical lab test. Clarification is needed regarding Chest X-Rays. Providers are encouraged to look at the language of the law.
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Question: Question regarding DR condition code for Hospice claims. Blanket waivers speak directly to COPs. Trying to understand if billing under the waiver, should every claim have DR condition code if they have implemented a waiver such as not having 5% volunteers?
Answer: While clarification is needed, they do not believe it was their intention to be on every claim, but on more specific claims that are subject to the waiver.
Question: Stimulus payments for SNF. If they request Advanced Payment, can they still apply for 1.5B grant to skilled nursing based on allocation system?
Answer: Generally, the Accelerated payment provisions have no limitations on them. You need to look at grant conditions when they come out, but they have not been released yet. When released, we will know more about how money will be distributed. At a high level, they are two separate programs.
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Question: Having trouble getting patients in SNF. Can inpatient hospital take these patients while awaiting admission to SNF?
Answer: Hospital admission criteria has not changed during public health emergency. CMS would not advise admittance as an inpatient if they don’t need to be admitted as an inpatient. Two midnight rule still applies.
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Question: Re: Provider Relief Fund. What about companies that don’t bill Medicare directly and bill through the SNF (e.g. rehab therapy companies)? They didn’t receive any funds under the current relief. Is CMS taking any steps to expand the public health fund?
Answer: Fund is not being administered through CMS, but will route the question.
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Question: SNF MDS timeframe requirements. What exactly does this mean? Do they still have to do MDS, but they do not have to be timely, or what is the waiver?
Answer: CMS is working on how that waiver is operationalized.
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Question: Can they code isolation on MDS for residents that they cohort who both have COVID19? Will an exception be made for this emergency? Generally, can only use the code. Also, for residents brought in for 14 day isolation under suspicion of COVID, can they code isolation for that on MDS even if there’s no active infection?
Answer: CMS will research and provide further guidance on this matter.
Please contact any member of our task force with your COVID-19 related questions.
Published April 21, 2020
