November 2020 Client Newsletter

New COVID Related 99072 CPT Code

After 2+ weeks of billing 99072 for the PPE supplies, we are getting some clarity but will still need to wait for more insurers to adjudicate the claims.

What we do know: ?

• Medicare so far has not covered and is denying. We have stopped billing it to Medicare.
• Horizon has it on their fee schedule however they say that doesn't mean they will pay it. Bizarre. We stopped entering that code for Horizon on 10/28.
• Interestingly, Local 54 (local casino union plan) did pay $6.75. We will continue to bill this.
• TriCare has paid $87.50 for 2 of the 3 claims billed. The 3rd is still pending.

Those that are denying it as saying it is:

• Incidental to the primary service/procedure, or
• Included with another service/procedure.
• Not paid separately.

Of course, they mean the same thing! No payment.

So, the early results are interesting. And likely some insurers may change their mind or be required by a state to cover it. Stay tuned for an update next month!

Note: Our reading of this is that the charge should be reasonably reflective of the actual cost of supplies & time used. In the event of an audit, it could be an issue if the charge is substantially higher resulting in a large profit.

 

CMS COVID-19 VACCINE GUIDANCE RELEASED OCTOBER 28, 2020

For our Physician clients, CMS issued the following as a Special Edition of "mlnconnects" on October 28th:

Coverage

"As a condition of receiving free COVID-19 vaccines from the federal government, providers will be prohibited from charging consumers for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.

Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay directly for the COVID-19 vaccine and its administration for beneficiaries enrolled in MA plans. MA plans would not be responsible for reimbursing providers to administer the vaccine during this time. Medicare Advantage beneficiaries also pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.

Medicaid: State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for most beneficiaries during the public health emergency. Following the public health emergency, depending on the population, states may have to evaluate cost sharing policies and may have to submit state plan amendments if updates are needed.

Private Plans: CMS, along with the Departments of Labor and the Treasury, is requiring that most private health plans and issuers cover a recommended COVID19 vaccine and its administration, both in-network and out-of-network, with no cost sharing. The rule also provides that out-of-network rates cannot be unreasonably low, and references CMS's reimbursement rates as a potential guideline for insurance companies.

Uninsured: For individuals who are uninsured, providers will be able to be reimbursed for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

Billing and Payment

The toolkits also address issues related to billing and payment. After the FDA either approves or authorizes a vaccine for COVID-19, CMS will identify the specific vaccine codes, by dose if necessary, and specific vaccine administration codes for each dose for Medicare payment. CMS and the American Medical Association (AMA) are working collaboratively on finalizing a new approach to report use of COVID-19 vaccines, which include separate vaccine-specific codes. Providers and insurance companies will be able to use these to bill for and track vaccinations for the different vaccines that are provided to their enrollees.

Medicare Payment

CMS also released new Medicare payment rates for COVID-19 vaccine administration. The Medicare payment rates will be $28.39 to administer singledose vaccines. For a COVID-19 vaccine requiring a series of two or more doses, the initial dose(s) administration payment rate will be $16.94, and $28.39 for the administration of the final dose in the series. These rates will be geographically adjusted and recognize the costs involved in administering the vaccine, including the additional resources involved with required public health reporting, conducting important outreach and patient education, and spending additional time with patients answering any questions they may have about the vaccine."