Miscellaneous COVID-19 FAQs

No. Pharmacists are not eligible to bill Medicare directly for their professional services on a CMS-1500 form. However, pharmacists may provide services under the “incident to” provisions, in which case the physician or NPP would be able to bill for the professional services provided by the pharmacist or on the CMS-1500 form. (05/05/2020)

For hospital-based pharmacists, CMS is deferring to the state scope-of-practice regulations. If a pharmacist is functioning within state scope-of-practice regulations, does not contradict your state emergency or pandemic plans, is providing services incident to a physician/non-physician practitioner (NPP) order, and the service is not one that is covered under Medicare Part D, then the facility may submit services provided by a pharmacist on a UB-04 claim form. These must also meet other requirements, such as medical necessity and documentation.² Telephone services, such as CPT® codes 98966-98968 or HCPCS codes G2061-G2063, may be reported by auxiliary staff, which includes pharmacists.²

If a pharmacist employed by the hospital provides services to patients in temporarily relocated off-campus provider-based departments (which may include patients’ homes) using telecommunications technology in accordance with the extraordinary circumstances exception outlined in the interim final rule, CMS-5531-IFC, then these services may be submitted on the UB-04 as well. (05/06/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 25 (April 30, 2020)

²Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, Telehealth Evaluation and Management (E/M) Services, page 2 (March 18, 2020)

Pharmacists and genetic counselors are not eligible to bill Medicare directly for their professional services on a CMS-1500 form. However, pharmacists and genetic counselors may provide services under the “incident to” provisions, in which case the physician or NPP would be able to bill for the professional services provided by the pharmacist or genetic counselor on the CMS-1500 form.

When pharmacists or genetic counselors are functioning as auxiliary staff of a hospital, CMS is deferring to the state scope-of-practice regulations. If the pharmacist or genetic counselor is functioning within state scope-of-practice regulations, does not contradict your state emergency or pandemic plans, is providing services incident to a physician/non-physician practitioner (NPP) order, and the service is not is covered under Medicare Part D, then the facility may bill for services that are provided by auxiliary staff on the UB-04 billing form. These must also meet other requirements, such as medical necessity and documentation.¹ (05/06/2020)

¹CMS-5531-IFC, “Medicare and Medicaid Programs, Basic health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program”, page 25 (April 30, 2020)

Effective January 1, 2020, CMS has suspended over 291,000 Procedure-to-Procedure (PTP) edits due to the COVID-19 public health emergency. This includes all of the PTP edits for the physicians that previously did not allow for reporting of CPT® code 99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services, with other E/M codes when reported by the same provider for the same patient. The complete listing of suspended edits can be downloaded from the CMS website here. (05/06/2020)

COVID-19 convalescent plasma has not yet been approved for use by the U.S. Food & Drug Administration (FDA). Due to this, your facility will need to be enrolled in a clinical trial and follow the clinical trial claims submission process.¹ According to uscovidplasma.org, the plasma may be transfused either centrally or peripherally.² Code selection is based upon whether the patient is inpatient or outpatient, and whether the transfusion is central or peripheral. For outpatient accounts, CPT® code 36430, Transfusion, blood or blood components, would be appropriate. Inpatient accounts would use ICD-10-PCS codes within the 302xxxx range. (04/23/2020)

¹Recommendations for Investigational COVID-19 Convalescent Plasma

²Clinical Investigator’s Brochure for Use of Convalescent Plasma to Treat Coronavirus-19 (COVID-19) Disease

The new time guidelines apply to Medicare and Medicaid. Adoption by other payers will be a payer-specific decision.¹ We recommend that you check with other payers to determine if they are adopting the new time guidelines during the public health emergency. (04/23/2020)

¹Medicare and Medicaid Program; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, pages 141-142

It is not possible to directly map codes for telephone visit services to new and established E/M codes. Codes should be selected based upon the documentation in the medical record and in accordance with the specific payer guidance. Additionally, it appears that at least certain state Medicaid programs are allowing the use of CPT®codes 99441-99443 to report telephone services. Therefore, we would recommend checking with your particular payers regarding appropriate reporting of these services to ensure accurate coding and reimbursement. (04/23/2020)

Teaching physicians can provide supervision virtually through audio/video real-time communications technology. Note that this does not apply in the case of surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, or anesthesia services. When the term “audio/video real-time communications technology” is used, this does not include audio-only communication.¹ (04/23/2020)

¹Teaching Hospitals, Teaching Physicians and Medical Residents: CMS Flexibilities to Fight COVID-19, page 1

The Centers for Medicare & Medicaid Services (CMS) has released two International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) codes, effective August 1, 2020 to report the administration of Remdesivir.

XW033E5, Introduction of Remdesivir Anti-infective into Peripheral Vein, Percutaneous Approach, New Technology Group 5

XW043E5, Introduction of Remdesivir Anti-infective into Central Vein, Percutaneous Approach, New Technology Group 5

The U.S. Food & Drug Administration (FDA) has provided emergency authorization for use of the drug on an inpatient-only basis. The drug should not be administered to a patient who is in observation status.[1]

(08/27/2020)

In order for payers to reimburse an item or service, the item or service needs to be a benefit. The Centers for Medicare & Medicaid Services (CMS) did not create a new benefit for the monoclonal antibody drugs used to treat COVID-19. Instead, they added COVID-19 medication treatments and vaccines to the existing Medicare Vaccine Benefit. The Monoclonal Antibody COVID-19 Infusion site states, “During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions (when furnished consistent with their respective EUAs) the same way it covers and pays for COVID-19 vaccines.”[1]

Even though these two drugs are infusions and revenue code 0260, IV Therapy – General Classification, makes more sense, the CMS subject matter experts (SMEs) stated during the CMS Office Hours Calls that claims should follow the same guidelines as vaccines. According to Chapter 18 of Pub. 100-04 (The Medicare Claims Processing Manual), revenue code 0771, Preventive Care Services – Vaccine Administration is required. Although the medications are infusions, the policy benefit where they are housed directs revenue code assignment for Medicare beneficiaries.[2]

(02/04/2021)

[1] Monoclonal Antibody COVID-19 Infusion, “Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction” available at https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion#Billing (January 7, 2021)

[2] Pub. 100-04 Medicare Claims Processing Manual, Chapter 18 Preventive and Screening Services, Subsection 10.2.2

“Claims Submitted to MACs Using Institutional Formats”, pages 35-36,

available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18pdf.pdf (October 3, 2016)

There are specific Healthcare Common Procedure Coding System (HCPCS) codes for reporting the infusions. HCPCS code M0239, Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring, and M0243, Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring, have been created for the infusion and a one-hour post-administration monitoring period. These administration codes do not need to follow the injection/infusion hierarchy, as CMS is considering these drugs to be part of the Medicare Vaccine Benefit.[1]

(02/04/2021)

Monoclonal antibody therapy drugs administered under the COVID-19 Infusion Program must be administered in accordance with the Emergency Use Authorization (EUA). The EUA specifically states that bamlanivimab and casirivimab/imdenivimab are not authorized for use in patients who are hospitalized due to COVID-19. However, this was discussed during the December 8, 2020 CMS Office Hours call, at which time the CMS subject matter experts stated that monoclonal antibody infusions would be treated similarly to the influenza vaccine when given to inpatients. On the rare occasion when monoclonal antibody therapy is administered to an inpatient who would benefit from the infusion but who is hospitalized for a condition other than COVID-19, the infusion should be reported on bill type 012X, INPATIENT HOSPITAL (MEDICARE PART B ONLY).[1]

(02/04/2021)

HCPCS codes M0239, Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring, and M0243, Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring, have been created to report the infusion and a one-hour post-administration monitoring period. The administration codes should be reported on the claim. The corresponding drug codes, Q0239, Injection, bamlanivimab-xxxx, 700 mg, and Q0243, Injection, casirivimab and imdevimab, 2400 mg, do not need to be on the claim until the facility is no longer receiving the drugs at no cost.[1]

(02/04/2021)

CMS guidance does not specifically state that a start time and stop time must be documented, but does state that appropriate medical documentation should support the medical necessity of the service, and include documentation supporting the terms of the EUA. The name of the ordering practitioner should be included. Because HCPCS codes M0239, Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring, and M0243, Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring, include the infusion and at least one hour of post-administration observation, you would need to have some time elements documented to ensure that the one-hour mark is met. If you do not have stop times documented, please contact your Medicare Administrative Contractor (MAC) for guidance.[1]

(02/04/2021)

CMS has stated that their preference is that claims do not contain the codes for the drugs as long as the drugs are provided free of charge during the current public health emergency (PHE). However, they recognize that existing payer edits may make this difficult and will therefore allow a nominal charge to be billed for the drug. There is expected to be additional guidance forthcoming once the current PHE is declared over. Unfortunately, payers may make their own rules. You would need to contact the payer to request information on their claims processing requirements.[1]

(02/04/2021)

This was discussed during the December 22, 2020 CMS Office Hours call. The CMS subject matter experts stated that the use of revenue code 0771, Preventive Care Services – Vaccine Administration, would earmark the administration codes as vaccine administration codes, so they shouldn’t interfere with infusions. During the CMS Office Hours calls, the subject matter experts have stated that they are planning on updating the CMS FAQ documents with the information, but no update for this scenario has yet been released.[1]

(02/04/2021)

According to the EUA for convalescent plasma, this treatment is allowed for use on an inpatient basis only. Additionally, the EUA has recently been updated so that only convalescent plasma blood products labeled as high titer are to be used, and those labeled low titer are now considered investigational.[1]

COVID-19 convalescent plasma is eligible for the New COVID-19 Treatments Add-on Payment (NCTAP). The presence of the ICD-10-PCS codes for the administration of convalescent plasma (XW13325, XW14325) and ICD-10-CM code U07.1, COVID-19, will trigger the NCTAP for discharges on or after November 2, 2020. Additionally, any other appropriate items necessary for claims submission should be used, such as condition codes.[2] Other data elements necessary for claims submission remain unchanged. You would still use any appropriate revenue codes, condition codes, etc., as necessary.

(02/04/2021)

[1] U.S. Food & Drug Administration, “EUA for the use of COVID-19 convalescent plasma” page 2, available at: https://www.fda.gov/media/141477/download (February 4, 2021)

[2] New COVID-19 Treatments Add-On Payment (NCTAP), “Coding for NCTAP”, available at: https://www.cms.gov/medicare/covid-19/new-covid-19-treatments-add-payment-nctap (January 27, 2021)

The U.S. Food & Drug Administration (FDA) has recently updated the EUA for COVID-19 convalescent plasma. This approval letter states that collection must go through a registered or licensed blood collection establishment. The plasma that is labeled as low titer is now considered investigational, while plasma labeled as high titer is approved. The approved tests for checking the titer, as well as the titer rates, are available in the EUA approval letter.[1] If the plasma is not investigational and your facility is a registered or licensed blood collection establishment, then you may charge for the collection.

There is no specific guidance that states you should not charge for the thawing of the plasma. The intent of the EUA and NCTAP is to have COVID-19 treatments available to patients, and current regulations are adding to the availability of the product. The regulations have not changed existing guidance for charging for blood products, so you may charge for the thawing, according to your normal charging practices. The EUA approval letter states that once thawed, the blood must be used within 5 days but does not address charges.[2]

(02/04/2021)

[1] U.S. Food & Drug Administration, “EUA for the use of COVID-19 convalescent plasma”, page 5, available at: https://www.fda.gov/media/141477/download (February 4, 2021)

[2] U.S. Food & Drug Administration, “EUA for the use of COVID-19 convalescent plasma”, page 8, available at: https://www.fda.gov/media/141477/download (February 4, 2021)