Medicare & Medicaid
For in-person evaluation & management (E/M) services conducted in the emergency department (ED), emergency physicians can use the five ED E/M codes (CPT codes 99281-99825).
Medicare and Medicaid are covering emergency telehealth services. Reimbursement of telehealth in Medicaid varies by state.
For Medicare, here is the official guidance:
Emergency physicians can perform telehealth services from any location, including the ED. CMS added the ED E/M codes (CPT codes 99281 to 99285), the critical care codes (CPT codes 99291 and 99292), and the observation codes (CPT codes 99217-99220, 99224-99226, and 99234-99236) to the list of approved Medicare telehealth services for the duration of the COVID-19 national emergency. The place of service code for emergency telehealth services is the same as what would be used if the services were delivered in-person (for the ED codes, the place of service is 23). They should include modifier 95 to each claim.
H.R. 6201, the Families First Coronavirus Response Act (FFCRA) signed by President Trump on March 18, made testing for COVID-19 universally free (no cost-sharing) for most Americans, even those who are uninsured.
Certain health plans must cover and waive patient cost-sharing for services “furnished to an individual during healthcare provider office visits (which includes in-person visits and telehealth visits), urgent care center visits, and emergency department visits that result in an order for or administration of COVID-19 test, but only to the extent the items and services relate to the furnishing or administration of the product or to the evaluation of the individual for purposes of determining the need of the individual for such product.” Thus, emergency department visits that lead to an order for or the administration of a test must be covered.
If the service is provided in-network, the health plan must pay the negotiated rate—which must apply for the duration of the national emergency. If the service is provided out-of-network, the health plan should reimburse the provider in an amount that equals the cash price for such service as listed by the provider on a public internet website, or the plan may negotiate a rate with the provider for less than such cash price. CMS encourages issuers to “to work with out-of-network providers” to “agree upon a rate to ensure that enrollees are not balance billed,” adding that multiple factors may be affecting patient access to in-network providers.
Medicare Advantage Organizations may waive or reduce enrollee cost-sharing for COVID-19 laboratory tests, telehealth benefits, or other services to address the outbreak, as long as they do so for all enrollees on a uniform basis.
Traditional Medicare CMS will waive Medicare beneficiaries’ cost-sharing (coinsurance and deductible) for visits and evaluation and management (E/M) services that result in an order for or administration of a COVID-19 test. This includes emergency department evaluation and management (E/M) services, hospital observation services, and office and other outpatient services. Please note that CMS has recently clarified that you must order or administer a COVID-19 test in order for the cost-sharing waiver to apply. If you evaluate a Medicare beneficiary with flu-like symptoms but wind up not ordering or administering a COVID-19 test, the waiver will not apply.
For each applicable claim, you should use the “CS modifier” and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services. The policy is retroactive to March 18 and lasts through the end of the COVID-19 national emergency. Thus, if you already have submitted eligible claims after March 18 without the CS modifier, you can contact your local Medicare Administrative Contractor (MAC) and request to resubmit the claims with the CS modifier to get 100 percent payment.
On April 13, 2020, CMS posted Medicaid coverage and cost-sharing guidance. In the guidance, CMS implements a provision of the FFCRA that adds a new optional Medicaid eligibility group for uninsured individuals during the COVID-19 public health emergency.
The services that states can cover for this new group of individuals include COVID-19 tests and “COVID-19 testing-related services.”
CMS defines COVID-19 testing-related services to include items and services for which payment is available under the state plan that are directly related to the administration of COVID-19 test or to the evaluation of a beneficiary for purposes of determining the need for such product, such as an Xray. COVID-19 testing-related services do not include services for the treatment of COVID-19.
States who cover these services for the uninsured will receive a 100 percent Federal Medical Assistance Percentage (FMAP). This means that the federal government will entirely cover the cost. However, the 100 percent match is not provided for COVID-19-related testing and diagnostic services provided to individuals covered under other Medicaid eligibility groups. Rather, for the traditional Medicaid populations, states will cover the cost of the waived cost-sharing but can qualify for a temporary 6.2 percentage point FMAP increase.
CMS has issued guidance related to payment for the infusion of monoclonal antibodies. In February 2021, ACEP clarified with CMS that for Medicare, the infusion can only be billed by the facility, not the individual clinician. However, when appropriate, hospital-based physicians could report the applicable evaluation and management (E/M) code, such as 99284/99204/99205.
With respect to billing a separate ED E/M code, additional guidance can be found in a CMS FAQ on pages 132-133:
Under current policy, if a physician or non-physician practitioner sees a beneficiary for the sole purpose of administering a vaccine (including a COVID-19 monoclonal antibody treatment), they may not routinely bill for an E&M visit. However, physicians and nonphysician practitioners can bill for an E&M service furnished on the same day as a vaccine (including a COVID-19 monoclonal antibody treatment) when the practitioner performs a medically necessary and significant, separately identifiable E&M visit in addition to the vaccine administration. During the PHE, we would anticipate this circumstance to be a common occurrence, and physicians and non-physician practitioners furnishing these services on the same day should add modifier “25” to the E&M code to identify it as a medically necessary E&M service furnished on the same day that another service is furnished by the same physician or other supplier. Similarly, hospital outpatient departments furnishing separately identifiable office visits on the same day a vaccine (including COVID-19 monoclonal antibody treatments) is administered should also add modifier “25” to identify a medically necessary E&M service furnished on the same day as another service.
Issuers offering non-grandfathered group or individual health insurance coverage must cover any qualifying coronavirus preventive service, including a COVID-19 vaccine, without imposing any cost-sharing requirements, such as a copay, coinsurance, or deductible.
This coverage must be provided no later than 15 business days after coronavirus preventive service is approved. Coverage does not depend on the type of FDA approval or authorization. These coverage requirements do not apply to a grandfathered health plans, excepted benefits, or short-term limited duration insurance.
For network providers, issuers will typically pay negotiated rates. For out-of-network providers, issuers will typically pay up to an allowed amount. During the COVID-19 PHE, the amount an issuer reimburses a provider for administration of a COVID-19 vaccine out of network must be reasonable, as determined in comparison to prevailing market rates for such service; one example of reasonable payment would be the Medicare reimbursement rate.
Providers who receive the COVID-19 vaccine free from the federal government are prohibited from seeking reimbursement from consumers for vaccine administration costs – whether as cost sharing or balance billing. Providers that administer vaccinations to patients without health insurance or whose insurance does not provide coverage of vaccination administration fees, may be able to file a claim with the provider relief fund, but may not charge enrollees directly for any vaccine administration costs.
For 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration for beneficiaries enrolled in Medicare Advantage plans will be made through the original fee-for-service Medicare program. Medicare Advantage plans should inform their contracted providers about this coverage policy and direct them to submit claims for administering the COVID-19 vaccine to the CMS MAC using product-specific codes for each vaccine approved.
Once the FDA has authorized or approved a COVID-19 vaccine, the vaccine and its administration, will be added to the list of preventive vaccines that are covered under Medicare Part B without coinsurance or deductible.
On March 15, 2021, CMS increased the Medicare payment rate for the administration of the COVID-19 vaccine. The rate for physicians, hospitals, pharmacies, and many other immunizers will be $40 to administer each dose. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses. The exact payment rate for the administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is delivered.
All states and territories are currently claiming this temporary FMAP increase. Medicaid coverage of COVID-19 vaccines and their administration without cost sharing is expected to be available for most Medicaid beneficiaries.
Since CMS expects that the initial supply of COVID-19 vaccines will be federally purchased, Medicaid would not reimburse providers for the vaccine. States have significant discretion in determining vaccine administration reimbursement rates that are paid to qualified providers that have a provider agreement with the Medicaid agency.
State Medicaid programs pay providers a state-determined administration fee for administering a vaccine. The regional maximum vaccine administration fees are established by CMS based on regional costs for vaccine administration.
Coding and Nomenclature
For more information on COVID-19 coding resources, please click here.