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HomeCOVID-19 Regulatory Updates - 10/25

American College of Physician Advisors

COVID-19 Updates & Resources

October 25, 2020

Created by a member of the ACPA Advisory Board via the ACPA Government Affairs Committee

As many parts of the country proceed into the second wave of SARS-CoV-2 infections, reports are increasing of hospitals running out of ICU beds and transferring patients to other hospitals – even to other states. The good news is that the mortality rate from infection seems to be significantly lower than early in the pandemic, perhaps due to improved treatments such as proning, high flow nasal cannula instead of early intubation, and dexamethasone. The jury seems to still be out on Remdesivir and convalescent plasma and there is little data on monoclonal antibody treatment, but it is certainly clear that there is no role for hydroxycholorquine. The outlook for a vaccine remains unclear with several candidates in testing but no data yet. We also now have to add another term to our lexicon – “long COVID.” These are patients who recover from their infection but have lingering effects from headaches to fatigue to pain and so on. It’s not clear how to treat this or what the long-term outlook is. We also have not yet seen a return of our “normal” volumes of heart attacks and strokes. It is not clear where they all went and why the numbers have not rebounded.


On the regulation front, the biggest news is that the Centers for Medicare and Medicaid Services (CMS) has let the auditors loose as of August 3rd. Seema Verma noted that the audit moratorium had to end to preserve the integrity of the Trust Fund, suggesting that, as with many situations, the bad actors are ruining it for everyone. But, CMS is doing it slowly, with the Medicare Administrative Contractors (MACs) still not resuming Targeted Probe and Educate audits. CMS has also instructed all auditors that if any provider needs a time extension as the result of a hardship due to COVID-19, they should allow it.

Since the audits have resumed, we have seen the Supplemental Medical Review Contractor (SMRC) announce that they will be auditing for inpatient admissions that received the extra 20% for having a COVID-19 ICD-10 code on the claim. But, it’s not that easy. Prior to September 1st, if the diagnosis was on the claim, the 20% was added. As with any diagnosis, it must be clinically valid to be reported. Previously, it did not require a positive test. The diagnosis could be made clinically, and it often was made with classic findings on labs and x-rays and tests which were not only in short supply, but also not very sensitive. Starting September 1st, there must be a positive SARS-CoV-2 test in the chart, either done at the hospital or elsewhere within 24 days. Unfortunately, notation of a positive test performed elsewhere is not good enough. The hospital either must repeat the test (and hope it’s not a false negative), have an actual copy of the outside test, or not get the extra 20%. If you have no positive test but the COVID-19 code is on the claim, you must place a billing note with NTE02 “No Pos Test” to stop the payment addition.

The Recovery Audit Contractors (RACs) are auditing again but so far, they aren’t looking at any COVID-19-related claims. They continue to get new issues approved, including medical necessity for total joint arthroplasty. We have heard rumors about audits of telehealth visit claims but so far, nothing has been confirmed. These claims are especially susceptible to audit since the code selection was, for the most part, time-based and it is relatively easy to calculate how much time was spent in visits and compare that to the number of hours in a day.


You probably know that Alex Azar extended the Public Health Emergency (PHE) again in early October. All waivers remain in place until late January 2021 unless cancelled earlier and this includes the Skilled Nursing Facility (SNF) 3-day stay requirement waiver. We have heard from hospitals that SNFs continue to refuse patients under the waiver, not trusting CMS that they will be paid. However, as long as the SNF places the DR condition code on the claim, it should be paid. If it’s not paid, it was a claim processing error by the MAC and a phone call should clear things up. Now, the waiver does state the transfer must be because of an effect of COVID-19, but that does not mean the patient must be infected with SARS-CoV-2. One facility came up with this templated phrase for use in the Electronic Health Record to satisfy their local SNFs (feel free to use it) – “Due to the COVID-19 pandemic, the patient and community's needs are most appropriately served by medically managing the patient's daily skilled needs in the SNF environment. The attending physician has determined this patient is medically stable to transfer to a Skilled Nursing Facility for continued care in order to allow for bed availability and staffing to care for more seriously ill patients and avoid further diversion of seriously ill patients."

The extension also allows non-rural or critical access hospitals to set up swing beds if they are unable to find an accepting SNF. You obviously have the option to keep the patient in the hospital and certify the days as medically necessary inpatient days, but you get no additional revenue until you hit outlier status. If you create and use swing beds, you can get paid a daily rate for the rehabilitation care you will be providing. It takes some paperwork, but then what doesn’t?


If you work with your revenue integrity or billing staff, you may be hearing about the -CS modifier. This modifier included on line items tells CMS that it is an E&M service that occurred to determine that COVID-19 testing was needed, and resulted in an order or a visit where COVID-19 testing was actually performed, in which case CMS would pay 100% of the allowed amount. The problem was that, as with many regulations, the wording was unclear and many providers thought the -CS could go on imaging and EKGs and other diagnostic testing that occurred during the visit. But, that was not correct. The MACs now have edits in place to stop the 100% payment if the -CS is used on the wrong codes. But, prior to the time of this publication, they were paid each time. So, now providers must decide if they should wait and see if the MACs will reprocess past claims, preemptively refund the money, or wait for the RACs to get approved to audit. What is your facility doing? It might be worth asking. Hopefully, they used the -CS properly from the beginning, even though at the time even CMS representatives were unclear on the proper usage.


The confusion over Q3014, the originating site fee, and G0463, the facility fee for an office visit, continues. Rather than explain it here, we suggest you read this article on – The topic is confusing, to say the least. Who would have ever thought we would be able to call a patient’s home a temporary hospital clinic location?


The CPT committee approved a new code, 99072, for use by non-facility-based providers to be added to all office visits during the PHE to account for added time and costs required to care for patients, including the extra screening and PPE. But, as of now, no payer has approved payment for this. CMS continues to talk internally.


On the campaign trail on October 24th, President Trump remarked that doctors and hospitals are putting COVID-19 on death certificates simply to make more money. This is hard to believe and insulting to the thousands of health care workers who have lost their lives to this pandemic and the many more who continue to treat patients with limited resources including reusing PPE. But, if your doctors or hospitals are indeed participating in this kind of behavior, find your compliance officer and report it immediately.