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New challenges continue to arise as we navigate the COVID-19 National Health Emergency. If you have questions about antigen testing and CMS rule changes, these three tips can help you optimize your revenue moving forward. Here are November’s three things to know.

Antigen tests for COVID-19 are covered by insurance plans.

While antigen tests are covered by insurance, your clinic needs to be diligent that claims are reported with CPT 87426. Since CMS has not set an allowable, reimbursement is all over the board from payer to payer—the average is between the high $30s and the low $40s—and several Blue Cross Blue Shield plans are driving that average down further.

A common question about antigen tests is whether providers can let patients pay for the test without submitting a claim. Generally speaking, providers under contract with a payer to provide covered services are obligated to bill insurance for those services, and to only collect the patient portions based on individual member benefits. Therefore, clinics are contractually bound to bill insurance.  However, a patient can choose to self-pay for services and not use their insurance for a visit. In that case, our experts recommend clinics get a signature each time that situation occurs.

The Health Resources & Services Administration Uninsured Portal is holding claims with CPT 87426 until a national allowable is set by CMS. It will be covered though payment on claims will be delayed. Experity is continuing to monitor this situation and will provide updates as they become available.

CMS Releases Relaxed COVID-19-Related Recoupment Schedule

Providers got good news when Medicare released new guidelines for recouping COVID-19-related accelerated and advance payments. Here are some of the key takeaways:

  • Repayment will begin a year after payment was issued, which is five months later than the original plan.
  • Medicare will automatically recoup 25 percent of payments otherwise owed to the provider for the next 11 months. During the subsequent six months, the amount will increase to 50 percent. At the end of that 29-month timeframe, CMS will issue letters requiring repayment of the balance subject to four percent interest (down from 10 percent in the original plan).
  • Providers can pay off the entire balance before or after the repayment window.

Read more details about accelerated and advance payments here.

The Scoop on Vaccinations

Immunizations are top-of-mind this time of year. Here are a few things to remember.

The kind of immunization service the practice provides will determine whether a patient is “new” or “established” for subsequent visits.

Once a patient has an immunization, they may still be regarded as new to the practice because the service was not a face-to-face service rendered by a physician or qualified healthcare professional (QHP).

For example, providers can bill a new patient visit when the patient is subsequently seen for a sick visit or well visit following nurse-visit only services. If the immunization is administered by a physician or QHP, patient should be coded as established.

Please note: There are some exceptions to this, and payers can also have different guidelines. Double-check your contractual agreements to ensure your clinic is following proper coding practices.

Vaccine administration can be reported separately from other services.

Per CPT® guidelines, if the provider performs a “significant separately identifiable” E/M service such as 99201-99215 (“Office or other outpatient visit for the evaluation and management of a new/established patient –”) or 99381-99396 (“Initial/ periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual –”), the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes.

However, if vaccine administration does occur at on the same date of service as an E/M service, modifier 25 must be appended to the E/M. Without this modifier, payment for the E/M code will be bundled into the vaccine administration for those payers following National Correct Coding Initiative (NCCI) edits.

Again, some exceptions apply. Check current CMS guidelines.

What about COVID vaccines?

According to a recent CMS Factsheet, an Interim Final Rule with Comment Period (IFC) was issued on October 28, 2020. This Interim Final Rule removes administrative barriers to eliminate potential delays to patient access to a lifesaving vaccine.

In addition, the rule:

  • Creates flexibilities for states maintaining Medicaid enrollment during the COVID 19 PHE
  • Establishes enhanced Medicare payments for new COVID-19 treatments
  • Takes steps to ensure price transparency for COVID-19 tests
  • Provides an extension of Performance Year 5 for the Comprehensive Care for Joint Replacement (CJR) model
  • Creates flexibilities in the public notice requirements and post-award public participation requirements for a State Innovation Waiver under Section 1332 of the Patient Protection and Affordable Care Act during the COVID-19 PHE.

The rule also includes provisions for adding COVID-19 vaccines to the list of preventative vaccines covered by Medicare Part B; requirements for private health plans; guidelines on State Innovation Waivers; an updated policy for maintaining Medicaid enrollment during the COVID-19 public health emergency; and price transparency requirements for COVID-19 diagnostic tests.


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