Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency • Survey
Medicare and Medicare Advantage Plan’s coverage of COVID-19 diagnostic testing for nursing home residents and patients started July 6, 2020 and continues until the end of the Public Health Emergency (PHE).
- Does covered diagnostic testing include asymptomatic patients and those that have been exposed to COVID-19 as well as those who have symptoms of COVID-19?
Answer: Testing is diagnostic and covered for asymptomatic residents with known or suspected exposure to an individual infected with COVID-19, including close and expanded contacts (e.g., there is an outbreak in the facility).
- Is initial (baseline) testing of asymptomatic residents without known or expected exposure to an individual infected with COVID-19 considered diagnostic and covered?
Answer: Initial viral testing of each resident (not known to have been previously diagnosed) in a nursing home is considered diagnostic and part of the recommended re-opening process.
- Is testing for resolution of a COVID-19 infection to determine when a resident no longer requires Transmission-Based Precautions covered?
Answer: Yes, this would be considered diagnostic and is covered.
- What are examples of non-diagnostic testing?
Answer: Repeat testing of asymptomatic residents after initial viral testing of all residents in response to an outbreak would not be diagnostic and would not be covered. Continued repeat testing of all previously negative residents until no new cases are identified is non-diagnostic.
The June 26, 2020, and July 1, 2020 revisions of this document address clarification of the 3-Day Qualifying Hospital Stay (QHS) Waiver, the Benefit Period Waiver, and related billing instructions.
- Does the waiver of the 3-Day Qualifying Hospital Stay for coverage of a SNF stay during the PHE need verification for individual cases?
Answer: No, it is a blanket waiver that exists nationwide for people affected by the emergency, who would be entitled to the SNF coverage under normal circumstances, but the PHE prevented a beneficiary from having the 3-day inpatient qualifying hospital stay.
- What is required when billing the Benefit Period Waiver (authorizing renewed SNF coverage without first having to start a new benefit period in certain circumstances) that is different from the 3-Day QHS waiver?
Answer: CMS requests that SNFs work with their MACs to provide the documentation needed to establish that the COVID-19 emergency applies for each benefit waiver claim. CMS states:
- It must be demonstrated that the beneficiary’s continued receipt of skilled SNF care is related to the PHE.
- The waiver does not apply to beneficiaries that are receiving ongoing skilled SNF care unrelated to the emergency.
- Ongoing skilled SNF care is considered to be emergency-related unless it is altogether unaffected by the COVID-19 emergency.
- How do you determine if the ongoing skilled care is related to the COVID-19 emergency?
Answer: CMS states that if you compare the course of treatment that the beneficiary is receiving to the care that would have been furnished “absent” the emergency and the two are not exactly the same, then the treatment has been affected by and is related to the emergency.
- How do SNFs bill for the QHS waiver?
Answer: SNFs must include the DR condition code on the claim.
- How do you bill for the Benefit Period waiver?
Answer: Follow these instructions:
- Submit a final discharge claim with patient status 01.
- Readmit the beneficiary (Day 101) to start the beneficiary period waiver.
- Use condition code DR (related to the PHE) and
- Use condition code 57 (readmission to bypass edits related to the 3-day stay being within 30 days)
- Put COVID100 in the remarks (identifies the claim as a benefit period waiver request)
- Ensure that the documentation in the medical record supports that care meets the waiver requirements as it may be subject to post payment review
- Track benefit days used in the benefit waiver spell and only submit claims with covered days 101-200
- Identify any no-pay claims related to the benefit period waiver by using condition code DR and including “BENEFITS EXHAUST” in the remark field
- Note: MACs must manually process claims to pay this waiver
- What if you have submitted a claim for a Benefit Period Waiver, billed the discharge, and readmission correctly, and it was rejected?
Answer: Cancel the rejected claim, do not submit a readjustment. Resubmit the canceled claim after it is canceled and be sure that COVID100 is in the remarks.
- What if you billed a claim for a Benefit Period Waiver and did not previously bill for a discharge on the last covered day?
Answer: Cancel the paid claim that includes the last covered coinsurance benefit day. Resubmit a final bill with the patient status of 01 once the canceled claim is processed. Cancel the initial benefit period waiver claim that was rejected for exhausted benefits. When it is canceled, then submit an initial bill for the benefit period (see the answer to question #9 for billing steps).
- What are the steps for admitting a patient under the Benefit Period Waiver?
Answer: You must complete a 5-day PPS Assessment, follow all the PDPM assessment rules, and include the HIPPS code from the new 5-day assessment on the claim. Note: The variable per diem schedule begins on Day 1.
Document history for MLN Matters SE20011 includes 8 revisions, including 3 in June and the one on July 1, 2020, since the initial release on March 16, 2020.
Please do not hesitate to reach out to HHI, Harmony Healthcare International (HHI), for further information on these or other regulatory updates.
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