CMS Clarifies Patient Financial Responsibility for COVID-19 Testing

EDITOR’S NOTE: news asked Dr. Ronald Hirsch, vice president at R1 RCM, to summarize the latest from the Centers for Medicare & Medicaid Services (CMS) on covering costs for COVID-19 care. In response, Dr. Hirsch provided RACmonitor the following summary.

When the first guidance on COVID-19 testing was released on March 13, CMS made it clear that there would be no beneficiary cost obligations for the COVID-19 test. This, though, was simply a basic tenet of the Medicare payment system; there is never beneficiary coinsurance or deductibles on approved lab tests.

When CMS waived the telehealth rules and allowed physicians to perform office and hospital visits via FaceTime and other similar modalities in late March, the U.S. Department of Health and Human Services Office of Inspector General announced that they would not sanction providers if they waived patient deductible and coinsurance amounts for these visits.

Then, on April 7, CMS announced that they would waive beneficiary coinsurance and any deductibles for any office or hospital visit during which a COVID-19 test was ordered, or the need for a test was evaluated. CMS noted that this includes claims for the professional fee for visits at all locations, including office visits, telehealth visits, emergency department visits, and nursing facility visits. Furthermore, if there is a facility fee associated with an outpatient visit, beneficiary coinsurance and deductible amounts should also be waived. The CMS notice includes hospital outpatient departments, critical access hospitals (CAHs), rural health clinics (RHCs), and federally qualified health centers (FQHCs) as eligible facilities.

CMS went on to state that the “CS” modifier should be placed on the line items for these services on the professional fee and facility fee claims so that they will process correctly. It should be noted that this modifier is only applicable to outpatient claims, and it should only be applied for that specific visit, and not on all services on the claim.

It is not clear how many encounters this encompasses. Physicians, many of whom are using telehealth now, have reported many encounters for the “worried well” or mildly symptomatic patient. In a large number of these visits, because of the shortage of test kits, the advice is given that the criteria for testing are not met, and the patient should self-isolate and seek care if symptoms worsen. The patient may be presumed to have COVID-19 and given treatment advice, but according to the criteria delineated in this new guideline from CMS, because a test was not performed or ordered, it would not be billed with the CS modifier and the payment would fall under the usual claims processing rules.

CMS also notes that this waiving of cost-sharing is effective as of March 18, and the agency instructs all providers that they would have to resubmit claims that have already been submitted with the CS modifier to get this provision applied. Finding these claims will certainly be time-consuming, although there is no indication that providers are required to resubmit claims.

This does bring with it some uncertainty. Since CMS is agreeing to cover 100 percent of allowed charges, what happens to the status of the claims that have already been submitted for the 80 percent for Medicare beneficiaries who have a supplemental plan that covers coinsurance and deductibles? Will these plans now refuse to process claims that cross over from the Medicare system and have any of the applicable ICD-10 codes, and will there be a demand for providers to resubmit them so that they do not have to pay the coinsurance or deductible? Will they continue to pay claims as usual? Or will they pay the claims as usual and then later seek to recoup the paid amount as an overpayment?

With every passing day, it seems more questions arise. Taking care of our patients and our caregivers should always remain our primary focus. As new issues arise, do your best, keep records, and adjustments can always be made once we migrate to our new normal.

Programming Note: Listen to Dr. Ronald Hirsch every Monday on Monitor Mondays, 10-10:30 a.m. EST.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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