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Last Modified: 7/12/2022 Location: FL, PR, USVI Business: Part A, Part B

COVID-19 billing alerts

First Coast wants to ensure your claims for COVID-19 related services process quickly and correctly. We’ve created a “COVID-19 Billing Alert” series to educate you on preventing claim errors we’re seeing or to answer questions we’re hearing from providers.

Use the CS modifier to waive cost-sharing – added March 5, 2021

You can use the CS modifier for COVID-19 testing-related services. The CS modifier waives the beneficiary cost-sharing, allowing the claim to pay at 100% of the fee schedule amount. The CS modifier does not need to be added to lab codes.
When the specimen for COVID-19 lab testing is collected by a hospital outpatient department, you can bill the new HCPCS code C9803 with the CS modifier to waive cost-sharing.
When the specimen for COVID-19 lab testing is collected by a physician office and the sole purpose of the visit is for specimen collection, you can bill CPT code 99211 with the CS modifier to waive cost-sharing. If the specimen collection is performed along with other professional services, such as a higher-level visit, then the higher-level code would be used for the visit and the specimen collection would not be separately payable.
For a full list of HCPCS/CPT codes that the cost-sharing can be waived, please review the section Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services in the MLN Special Edition (SE) 20011 external pdf file.

Claims rejecting for Medicare Advantage beneficiaries require CC 78 – added March 1, 2021

Recent data analysis shows an increase in Part A claims for COVID-19 vaccines and infusions being rejected for patients enrolled in a Medicare Advantage plan. These claims are rejecting with reason code U5233.
When billing for the COVID-19 vaccines and/or infusion products to Medicare Part A, you must include condition code (CC) A6 and 78 are on the claim. Condition code A6 will allow 100% payment and condition code 78 indicates the service is new coverage not implemented by the Medicare Advantage plan.
If your claim was rejected for missing CC 78, please correct, and resubmit your claim.
For additional information review the COVID-19 vaccine and monoclonal antibody billing for Part A providers instructions.
Note: On or after January 1, 2022, claims for vaccine or mAb administrations for Medicare Advantage enrollees should be submitted to the Medicare Advantage plan.

Place of service (POS) for Part B claims – added February 10, 2021

When selecting the POS code to bill on your Part B claim, you should consider several factors.
Where are the services being rendered?
Is it an extension site (e.g., tent, transitioned gymnasium, or a converted non-clinical location)?
If it is an extension site, who established the site? The clinic/group practice or hospital?
Who’s providing the supplies and materials for the services being rendered?
Is the clinic/group practice or hospital staff rendering the service?
These questions will help you in determining who should bill for the service and the place of service code to use on Part B claims. To facilitate correct billing and prevent duplicate billing, we recommend discussion between the providers involved in the service, including the hospital, hospitalist groups, clinic/groups practices, etc.
Scenario #1
A patient presents to the emergency room (ER) with mild to moderate COVID-19 symptoms and a positive test result from a previously administered test. The attending ER physician examine the patient and orders monoclonal antibody infusion (mAb). The nursing staff administers the mAb infusion. Since the location is the ER and the hospital nursing staff is administering the mAb, we expect the hospital to bill for the mAb infusion to Part A. The ER physician would bill Part B with POS code 23 (ER – Hospital) and the applicable evaluation and management (E/M) service. If a Part B claim is submitted for mAb in POS 19 (Off Campus – Outpatient Hospital), 22 (On Campus – Outpatient Hospital) or 23 (ER – Hospital), the service will be denied since it should be submitted to Part A.
Scenario #2
A clinic/group practice has set up a temporary site for administering COVID-19 vaccines. The clinic/group practice is providing the supplies and staff for administering the vaccines. The location for the temporary site is on the campus of a nearby hospital. Although the hospital has provided the location for the temporary site, the hospital is not providing supplies nor staff for providing the vaccines. The hospital would not bill for any services since they are not providing the supplies or staff. The clinic/group practice would bill Part B for the administration of the vaccine and use POS code 11 (Office) since the temporary location is an extension of their practice.
Scenario #3
A clinic/group practice has contracted with a hospital to provide care for patients that have tested positive for COVID-19 and has mild to moderate symptoms. The hospital has set up a temporary location in a repurposed convention center to administer mAb infusion as an outpatient service. The hospital is providing the supplies and nursing staff. Physicians and nonphysician practitioners from the clinic/group practice are working at the temporary location to examine the patients and order the mAb infusion. The hospital nursing staff administers the mAb infusion based on the practitioner’s order. The hospital would bill for the mAb infusion to Part A. The contracted physician that ordered the mAb would bill Part B for the applicable E/M service with POS code 19 (Off Campus – Outpatient Hospital) or 22 (On Campus – Outpatient Hospital) since the temporary site is an extension of the hospital’s outpatient department.

Billing the administration codes – added February 1, 2021

When COVID-19 vaccine and monoclonal antibody doses are provided by the government free of charge, only bill for the administration. Don't include the vaccine or infusion drug codes on the claim when the vaccines or infusion drugs are free. Single claim or roster claim billing should include only the administration codes.
Note: If your software requires you to submit the vaccine or infusion drug codes with the administrations, you should submit the billed amount as $0.01.

Billing Medicare Advantage beneficiaries – added February 1, 2021

CMS has provided guidance for Medicare Advantage plan beneficiaries. The vaccine and infusion administrations claims should be submitted to traditional Medicare for dates of services in 2020 and 2021.
Note: On or after January 1, 2022, claims for vaccine or mAb administrations for Medicare Advantage enrollees should be submitted to the Medicare Advantage plan.
Billing traditional Medicare
For Part A and Part B claims, submit the claim with the Medicare Beneficiary Identifier (MBI). If the patient does not have the Medicare card or MBI, you can use the MBI Lookup in the SPOT. SPOT is First Coast’s free online portal. Review the SPOT webpage for more information on enrolling and using the tool.
For Part A and Part B claims, submit only the administration codes when vaccine and monoclonal antibody (mAb) doses are provided by the government free of charge. You should submit the billed amount as $0.01 if your software requires you submit the vaccine or infusion drug codes with the administrations.
For Part A claims, include the CC 78: New coverage not implemented by Medicare Advantage.
For Part A claims, do not submit roster billing since the Fiscal Intermediary Standard System (FISS)/direct data entry (DDE) does not allow CC 78.
Note: Having trouble getting the MBI from your Medicare Advantage beneficiaries? Use this CMS resource handout external link to encourage your Medicare Advantage beneficiaries to bring their original Medicare card for their vaccine and mAb infusion treatment visits.
For more information on billing, please see the resources below:

MSP questionnaire – added February 1, 2021

Providers are required to determine whether Medicare is a primary or secondary payer for Medicare beneficiaries when presenting for outpatient encounters. No exceptions or waivers have been granted for this requirement. The provider must ask if the Medicare beneficiary has other insurance coverage.
Note: If you can submit and receive a X12 270/271 transaction, you can use this for confirming insurance information. You can verify with the Medicare beneficiary if the information is valid or if there has been a change instead of asking the questions. You must ask the questions if there has been a change or the beneficiary is unsure.
Please review the Internet-only manual (IOM) Publication 100-05, Chapter 3, Section 20.2 external pdf file for more information utilizing the X12 270/271 transaction instead of the MSP questionnaire.
Medicare Advantage beneficiaries
Updated March 31: While there has been a long-standing exception for Medicare Advantage plan members which does not require hospitals to ask the MSP questions or to collect, maintain, or report this information, CMS does expect you to determine your Medicare patients insurance coverage when administering COVID-19 vaccines during the PHE. This includes gathering information from patients with original Medicare and from patients enrolled in Medicare Advantage plans. Please refer to CMS’ Medicare Billing for COVID-19 Vaccine Shot Administration external link page for more information.

Part B entitlement – added February 1, 2021

Part of your responsibility as a provider is to verify entitlement prior to claim submission and make a good faith effort to figure out who is primary and who is secondary. There are many self-service options available to verify eligibility:
SPOT
The Medicare beneficiary must have Part B Medicare for the vaccine to be reimbursed by Medicare. Because it will be covered under Part B, the COVID vaccine and its administration will not be covered under Part D. In the absence of Part B coverage, the provider should bill the insurance the beneficiary does have and if there is no other insurance, the provider can request reimbursement for the administration through the Provider Relief Fund external link.

Additional information

Please visit First Coast’s Coronavirus (COVID-19) webpage for additional information on billing the administration for COVID-19 vaccines and infusions.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.