CMS issues billing instructions for COVID-19 related waivers and payment rates for diagnostic tests

On March 16, CMS announced blanket waivers of certain Medicare requirements to prevent gaps in care for beneficiaries affected by the novel coronavirus (COVID-19) public health emergency. SE20011 contains details of the waivers and billing instructions as well as links to related Q&As.

CMS issued the following waivers:

• Skilled nursing facilities (SNF):
  • Waiver of the requirement for a three-day prior hospitalization. This waiver provides temporary emergency coverage for individuals who are evacuated, transferred, or otherwise dislocated as a result of the public health emergency. It also authorizes renewed SNF coverage for beneficiaries who have exhausted their SNF benefits.
  • Waiver on the time frame requirements of minimum data set assessments and transmissions.
• Home health agencies:
  • Waiver on the time frames related to OASIS transmission.
  • Waiver of the autocancellation date of requests for anticipated payment.
• Critical access hospitals (CAH):
  • Waiver of the requirements that CAHs limit their number of beds to 25 and length of stay to 96 hours.
• Acute care hospitals:
  • Waiver of the restrictions on housing acute care patients in excluded distinct parts units. This waiver allows hospitals to place patients in excluded distinct parts units when the distinct parts units’ beds are appropriate for inpatient care. The hospital should bill for the care and the documentation should note that the patient is an acute care patient housed in the excluded unit because of capacity issues related to the public health emergency.
  • Waiver of the restrictions on care for excluded inpatient psychiatric unit patients in an acute care unit. This waiver allows hospitals to relocate patients from excluded distinct part psychiatric units to acute care units as a result of the public health emergency. The medical record must note that the patient is a psychiatric inpatient being cared for in an acute care bed due to capacity or other circumstances related to the public health emergency. The hospital should continue to bill for inpatient psychiatric services under the inpatient psychiatric facility prospective payment system.
• Inpatient rehabilitation facilities (IRF):
  • Waiver of the restrictions on care for excluded inpatient rehabilitation unit patients in an acute care unit. This waiver allows hospitals to relocate inpatients from excluded distinct part rehabilitation units to acute care units. The medical record must note that the patient is a rehabilitation inpatient being cared for in an acute care unit due to capacity or other circumstances related to the public health emergency. The hospital should continue to bill for IRF services under the IRF prospective payment system. IRFs can exclude from their population patients admitted solely to respond to the public health emergency for purposes of calculating the thresholds to receive IRF payment, provided the circumstance is clearly documented in patients’ medical records. This waiver also applies to facilities that are currently attempting to obtain classification as an IRF.
• Long-term acute care hospitals (LTCH):
  • Waiver of the 25-day average length of the stay requirement. This allows LTCHs to exclude patients who are admitted or discharged to meet the demands of the public health emergency from the 25-day average length of stay requirement.

Organizations do not need to apply for any of these waivers. Additional waivers for DMEPOS are detailed in SE20011.

CMS issued a condition code and a modifier that should be applied to applicable claims for services that fall under the waivers. Condition code DR (disaster related) should be used for institutional billing, and modifier CR (catastrophe related) should be used for billing Part B.

SE20011 provides a link to instructions to request an individual waiver if there is not blanket waiver.

For more information, organizations can contact their MACs and refer to CMS’ Q&As that apply without a Section 1135 waiver or other formal waiver and Q&As that apply only with a Section 1135 or Section 1812(f) waiver.

On March 14, CMS posted a fact sheet with information on pricing of the CDC and non-CDC COVID-19 diagnostic tests. There is no beneficiary cost-sharing for these tests. Medicare’s payment for the CDC test is approximately $36 and for the non-CDC test is approximately $51. MACs' prices may vary slightly. See the fact sheet for a list of the MACs' prices.

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