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COVID Lab Billing

Shasta McClary

August 26, 2020

Background Info

 Recommended diagnostic testing includes [These Tests are Generally Covered]:

Initial viral testing due to an outbreak

Viral Testing of Residents for SARS-CoV-2

Recommended testing to determine Resolution of Infection with SARS-CoV-2

Recommended non-diagnostic testing includes [These tests are generally Non-Covered]:

Viral and Antibody Testing for purposes of Contact Tracing

The CDC recommends that SNFs choose laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) and should be selected for facility-wide testing intended to inform infection prevention initiatives to prevent and limit transmission.

Ideally, one laboratory should be selected to process specimens from both HCP and residents to facilitate data collection and analysis.

Unfortunately, neither CMS nor the CDC requires a laboratory to bill various insurance carriers and therefore many labs choose to bill the SNF directly. CMS recommends that the SNF make pre-arrangements with laboratories for processing results, before mass SNF-wide testing is completed. Under section 40.4 of the Medicare Claims processing manual Chapter 16 the SNF is permitted to bill Medicare Part B for laboratory tests when those tests are provided “under an arrangement” with the lab.

This is applicable to patients in a non-Medicare Part A covered stay in a SNF and not to those residents in Medicare-Part A covered stays (whose bundled lab tests would be bundled to the SNF under Part A’s SNF benefit).

Cost Sharing

Medicare Administrative Contactors (MACs) and Medicare Advantage plans have been notified by CMS to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients in accordance with CDC guidelines.

Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services. The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services.

Billing COVID Testing

  • The SNF may bill for those codes that are CLIA waived codes assuming the SNF has a CLIA waiver.
  • In addition, the SNF may bill for those codes provided by a laboratory when the SNF has an “under arrangement” agreement with the laboratory. See section 40.4 of the Medicare Claims processing manual Chapter 16 for SNF Part B laboratory billing.
  • If the resident is NOT in a Part A stay and has Medicare B benefits, and the SNF has an arrangement or contract to pay the lab the SNF may then bill Medicare B for reimbursement of the processing of the sample and for the collection, if collection was done and billed to the SNF by the lab.
  • In the instance where the SNF collects the sample the SNF may NOT bill for the specimen collection fee. This fee is not CLIA waived and it is not provided by the lab under an arrangement.
  • Starting May 8, 2020 and effective for DOS on or after March 20, 2020 codes U0002 [COVID-19 LAB TEST NON-CDC] and 87635 [SARS-COV-2 COVID-19 AMP PRB] can be submitted by facilities with a valid, current CLIA waiver with the QW modifier.
  • For Medicare Part A Stay residents, all lab tests and the specimen collection codes are bundled back to the SNF in accordance with SNF Consolidated Billing rules for diagnostic testing. If the resident is in a Medicare Part A Stay the swabbing (G2024) and testing (U0001, U0002, U0003, U0004) are bundled into the SNF Part A payment and you will need to pay the Lab for the type of test performed.
  • If your resident is under a Medicare Advantage Plan, under Section 6003 of the Families First Coronavirus Response Act and Section 3713 of the CARES Act, (with the exception of Medicare Advantage Medical Savings Account plans), Medicare Advantage Organizations (MAOs) must not charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for:

• Clinical laboratory tests for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19 and the administration of such tests;

• Specified COVID-19 testing-related services (as described in section 1833(cc)(1)) for which payment would be payable under a specified outpatient payment provision described in section 1833(cc)(2); and

• COVID-19 vaccines and the administration of such vaccines, as described in section 1861(s)(10)(A)

  • ***PLEASE NOTE THAT MANY MCO’S ARE NOT PROCESSING COVID TESTING CLAIMS TIMELY
  • Original Medicare and Medicare Advantage plans will cover COVID-19 lab tests consistent with CDC guidance.

Billing Guidelines

****SNF MUST HAVE CLIA WAIVER TO BE ABLE TO BILL****

TOB = 22X

Acceptable HCPCS :

CodeModifier NeededDescriptionDOS EffectiveMedicare AllowableType of Test
U0002QWCOVID-19 LAB TEST NON-CDC2.4.2020FI SPECIFICVIRAL
87635QWSARS-COV-2 COVID 19 AMP PRB3.13.2020FI SPECIFICVIRAL
87426QWCORONAVIRUS AG IA6.25.2020FI SPECIFICVIRAL

****SNF MUST HAVE VALID CLIA WAIVER AND “UNDER ARRANGEMENT” AGREEMENT WITH LAB****

CodeModifier NeededDescriptionDOS EffectiveMedicare AllowableType of Test
U0001 2019-NCOV DIAGNOSTIC P2.4.2020FI SPECIFICVIRAL
U0003 COV-19 AMP PRB HGH THRUPUT4.14.2020$100.00VIRAL
U0004 COV-19 TEST NON-CDC HGH THRU4.14.2020$100.00VIRAL
86328 IA NFCT AB SARSCOV2 COVID 194.10.2020FI SPECIFICANTIBODY
86769 SARS-COV-2 COVID-19 ANTIBODY4.10.2020FI SPECIFICANTIBODY

CLIA Certification

APPLICATION FOR A CLIA CERTIFICATE:  FORM CMS-116

The Centers for Medicare & Medicaid Services (CMS) has made available the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Application for Certification Form, CMS-116.  This form should be completed and mailed to the address of the local State Agency (PDF) for the state in which your laboratory resides. CMS-116 form and its instructions are found as a download under the Resources section below and contain the following information:

  • The CLIA application form, CMS-116;
  • Instructions for completing the CMS-116;
  • Guidelines for counting tests for CLIA; and
  • Tests commonly performed and their corresponding laboratory specialties/subspecialties.

Resources

CMS Lab COVID Testing FAQs

CMS-116 Application and Instructions

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