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In an effort to mitigate the spread of the coronavirus while continuing to provide critical healthcare services, the Centers for Disease Control and Prevention (CDC) has advised healthcare organizations to explore alternatives to face-to-face encounters with patients. This recommendation, coupled with the particular needs of COVID-19 patient diagnosis and treatment, has resulted in a constantly evolving series of changes to payer-required coding and billing requirements.
ECG has summarized topics with reimbursement impact into the following categories:
The remainder of this resource guide provides key tactical information and considerations for payer coding and billing requirements. ECG will continue to monitor relevant government and commercial payer bulletin releases, but provider organizations should always consult CMS and official payer communications when implementing new or updated coding and billing processes.
Nearly all payers are allowing reimbursement for telehealth services, regardless of COVID-19 diagnosis. While specific requirements vary by payer, telehealth visits are indicated by using the appropriate combination of place-of-service (POS) codes, CPT/HCPCS codes, and/or CPT modifiers.
In table 1, ECG has defined the primary unique identifiers your organization would be eligible to use for telehealth reimbursement; see table 2 for published unique identifier combination requirements for major national payers.
When COVID-19 screenings are performed, specific CPT and diagnosis codes defined throughout this section must be used. Additional non-COVID-19-related CPT codes and diagnoses could be added as appropriate, and standard sequencing logic should be applied.
Providers who are only performing the collection of the patient specimen should bill C9803 if performed in a hospital outpatient department and 99211 if performed in a physician office setting.
When billing accompanying diagnoses, providers should follow the guidance outlined in table 4.
As indicated in the previous section, a specific diagnosis code (U07.1) was recently created to represent a confirmed COVID-19 diagnosis; this code became effective on April 1, 2020, and recent legislation in the CARES Act allows for a 20% increase in total Medicare MS-DRG payment when this code is present.
For all dates of service prior to April 1, 2020, a more generic diagnosis code was used (B97.29). The B97.29 code by definition cannot be placed in the primary diagnosis position as the condition that caused the admission; however, the U07.01 code can be placed in the primary position, which allows for more flexible and accurate coding. Table 5 was developed using common patient manifestations assuming COVID-19 as the principal diagnosis.
Organizations should ensure the correct diagnosis code and sequencing is used based on the patient’s date of service or discharge date. Clinicians and coders should consider the following information when coding:
Organizations’ CDI and provider education specialists should develop communication materials for clinicians to use in optimizing coding and reimbursement.
As your organization navigates the ever-changing coding and billing requirements for COVID-19, be sure to:
As the pandemic develops, coding and billing requirements will continue to evolve. Provider organizations must safeguard telehealth and COVID-19-related revenues by approaching coding and billing in a methodical and organized fashion. These developed processes will result in maximum reimbursement for provided services.
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