Medicare & Medicaid Seek Faster COVID-19 Test Results
What Your Medical Practice Can Expect with Regard to Reimbursement
During the global pandemic, the Centers for Medicare & Medicaid Services have worked tirelessly to ensure patients who test positive to COVID-19 are notified swiftly and receive medical treatment in a timely manner.
In October 2020, CMS announced new actions designed to expedite COVID-19 test results. Beginning January 1, 2021, CMS’ policies will change again. Assistentcy, your outsourced medical billing expert and extended business office, has updated information to share with you regarding Medicare and Medicaid reimbursement.
Changes to Medical Reimbursement, Effective January 1, 2021
In 2020, CMS increased Medicare reimbursement to labs performing COVID testing from $51 to $100 per test. Starting in 2021, Medicare will pay the $100 reimbursement to labs that complete high throughput COVID-19 diagnostic tests within two calendar days of specimen collection. Laboratories that take longer than two calendar days to complete the tests will receive only $75.
Essentially, the reward for rapid test result delivery encourages medical care teams to react quickly to positive test results, including making important treatment decisions, physically isolating, and contact tracing.
Amended Administrative Ruling (CMS 2020-1-R2) and HCPCS Code U0005
While the base payment for COVID-19 diagnostic tests drops $25 effective January 1, laboratories that complete individual tests within two calendar days, and also complete the majority of their COVID-19 tests within the same timeframe for all patients – not just Medicare patients – within the previous month, will receive an additional $25 reimbursement, totaling $100 when combined with the base payment.
These actions are implemented under the amended Administrative Ruling CMS 2020-1R2 and coding instructions, HCPCS Code U0005.
Effects on Medical Laboratories with Regard to Medical Billing and Coding
Medical laboratories seeking to receive the full $100 reimbursement will need to update their logistics and sample collections processes to meet the two-day processing deadline. The two-day limit begins at the time the sample is collected, not when the lab receives it. The policy is measured on a monthly basis.
To determine proper medical coding, review the following scenarios.
In the previous month, the lab completed the majority of all COVID-19 tests (for all payers, not just Medicare) within two days or less from sample collection. Two codes are billed:
- COVID-19 test (U0004), which pays $75
- Fast completion code (U0005), which pays $25
Both codes should be billed in this scenario to receive the full $100 reimbursement per test.
If the lab did not complete the majority of all COVID-19 tests the prior months within two days or less from sample collection (for all payers, not just Medicare), then only one code is billed: COVID-19 test (U0004), which pays $75.
Remember Other COVID-19-Related Reimbursement Information
- Effective January 1, 2021 or sooner, many insurance payers will cease waiving costs for telehealth or virtual visits. Already, some payers have reduced their waivers to include only in-network providers. Waivers vary from payer-to-payer, so expect continual changes through 2021 and beyond.
- For confirmed COVID-19 cases, medical practices should assign code U07.1, COVID-19, even if the patient is asymptomatic.
- For patients who are suspected as having COVID-19, assign a code that describes the reason for the medical encounter, such as Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.
- If a patient is seen for a concern about possible exposure to coronavirus, but it is ruled out after evaluation, use code Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out.
- For codes requiring sequencing, like when COVID-19 is the principal diagnosis, code U.07.1, COVID-19 should be sequenced first, followed by codes for associated conditions, such as pneumonia (J12.89); lower respiratory infection (J22); or acute bronchitis (J20.8).
- For asymptomatic patients receiving COVID-19 screening without a known exposure, assign code Z11.59, Encounter for screening for other viral diseases.
- If a patient has symptoms of coronavirus and has had actual or suspected contact with someone confirmed positive for it, assign code Z11.59, Encounter for screening other viral diseases.
Let Assistentcy Handle Medical Payment Logistics for Your Practice
The world of medical billing changes nearly constantly. Keeping up with it is time consuming. Partner with Assistentcy for EBO medical billing and simplify your team’s responsibilities. We understand that every medical organization is different; we acknowledge and celebrate those differences by assembling a customized early-out program with procedures and policies that align to your operations and compliance practices. Collaboration between us and your practice is key – and we make sure it’s seamless.