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Provider Billing FAQs

Novel Coronavirus (COVID-19) Update for CCA Providers

Date 3/8/2021

Provider Billing Frequently Asked Questions (FAQ)

Commonwealth Care Alliance (CCA) is continuing to monitor updates from CMS and EOHHS regarding the COVID-19 Public Health Emergency (PHE). A PHE was declared across the United States on 1/31/2020. Effective 4/1/2020, providers can bill for COVID19 related services for service dates 2/4/2020 onward. Please see our newly implemented payment policies on COVID-19 and Telemedicine for additional guidance.
As more information becomes available, the FAQs will be updated.

Q. Who is eligible to receive the COVID-19 vaccine?

A. As of the publication of this bulletin, the COVID-19 vaccine eligibility is currently in Phase 2 – Group 2 which includes: Clinical and Non-clinical healthcare workers doing direct and COVID-facing care, Long Term Care Facilities, Rest Homes, Assisted Living Facilities, First Responders (EMS, Fire, Police), Congregate Care Settings (including corrections and shelters), Home-based Healthcare Workers, Healthcare workers doing non-COVID facing care.

For more information on the eligibility on the vaccine distribution timeline and clarification on Phases 1-3, please see When Can I Get the COVID-19 Vaccine?

Q. Should providers be submitting claims for COVID-19 vaccines and Monoclonal Antibody treatments directly to CCA? What codes should be submitted?

A. Providers should submit claims to original Medicare for both vaccines and Monoclonal Antibody treatments for all CCA members who are Medicare beneficiaries.

For SCO members who are eligible for Medicaid-only, claims should be submitted directly to CCA.

Claim submissions for these services should be submitted accordingly through 12/31/2021 unless directed otherwise. It is the provider’s responsibility to confirm member eligibility prior to rendering these services.

Q. Where can I inquire about receiving vaccine supplies?

A. Please review the guidance for eligibility for the vaccine program. https://www.mass.gov/info-details/massachusetts-covid-19-vaccine-program-mcvp-overview#eligibility-to-receive-covid-19-vaccine-supply-

Q. What codes should I be submitting for COVID-19 Monoclonal Antibody treatment and what can providers expect to be reimbursed?

A. As stated above, these claims should be submitted to Medicare through 12/31/2021.

Q0239Injection, bamlanivimab, 700 mg  Eff. 11/10/2020
M0239Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring  Eff. 11/10/2020
Q0243Injection, casirivimab and imdevimab, 2400 mg  Eff. 11/21/2020
M0243Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring  Eff. 11/21/2020

Q. What codes should I be submitting for COVID-19 vaccinations and what can providers expect to be reimbursed?

A. Please review the table below for vaccine and administration coding and effective dates.

As stated above, Medicare should be billed for vaccines and payment will be at their established rates. Reimbursement for Medicaid-only SCO members will be reimbursed at MassHealth established rates. Please note, providers will not receive reimbursement for the vaccines, only for the administration of the vaccines.

As of the publication date of this bulletin, two vaccines are not yet approved for use but have CPT codes available for use as included below. These CPT codes should not be utilized until the vaccines are approved for distribution and use.

91300, SL  Pfizer-Biontech Covid-19 VaccineAdministration: 0001A 1st dose 0002A 2nd doseEff. 12/11/2020
91301, SL  Moderna Covid-19 Vaccine  Administration: 0011A 1st dose 0012A 2nd doseEff. 12/18/2020      
91302 (modifier TBD) AstraZeneca Covid-19 VaccineAdministration: 0021A 1st dose 0022A 2nd dose  EFFECTIVE DATE TBD  
91303 (modifier TBD) Janssen Covid-19 VaccineAdministration: 0031AEFFECTIVE DATE TBD  

Q. Will my reimbursement change due to COVID-19?

A. Yes, in some cases. CMS released direction to waive sequestration for dates of service 5/1/20–3/31/21 (see CARES Act and Consolidated Appropriations Act of 2021). CCA has updated fee schedules to accommodate this waiver. Inpatient stays relating to COVID-19 diagnoses have had their DRG weight increased by 20% for the operating portion of the payment under the MS-DRG system. CCA has accommodated this change where applicable. Note: Admissions occurring on or after September 1, 2020 are eligible for the 20% increase in the MS-DRG weighting factor. Providers will be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. See MLN article SE0015 for details.

Additionally, EOHHS released temporary rate increases for services associated with PCA Services, Surgery and Anesthesia, Ambulance and Wheelchair, Radiology, Home Health, Certain Substance Abuse Related Services and Addictive Disorder Programs. CCA is working diligently to ensure all claims processed during the public health emergency are adjudicated at the appropriate rate; some claims are subject to rate increases and may be automatically reprocessed. As of August 2020, payments for all retroactive adjustments, including related increases, for claims received throughout the Public Health Emergency have been completed. CCA is continuing to monitor the issuance of guidance related to rate adjustments and will continue to adjust claims in accordance with guidance and within timeframes specified CMS and EOHHS.

Specific to Adult Day Health (ADH) facilities, MassHealth has released specific increases associated with open ADH facilities and transportation services. CCA is working diligently to implement mandated rate increases detailed in Managed Care Entity bulletin 43. As part of this bulletin, providers are required to submit encounter logs for provided services. Please ensure all logs have been submitted for services billed.

Specific to Federally Qualified Health Centers (FQHCs), payment for virtual communication services now include online digital evaluation and management services. Online digital evaluation and management services are non-face-to-face, patient-initiated, digital communications using a secure patient portal.

The online digital evaluation and management codes that are billable during the COVID-19 PHE are:

• CPT code 99421 (5-10 minutes over a 7-day period)

• CPT code 99422 (11-20 minutes over a 7-day period)

• CPT code 99423 (21 minutes or more over a 7-day period)

To receive payment for the new online digital evaluation and management (CPT codes 99421, 99433, and 99423) or virtual communication services (HCPCS codes G2012 and G2010), Rural Health Centers (RHCs) and FQHCs must submit claims with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services. CCA is actively working to incorporate this increased rate. Any claims which were paid at the original rate with Date of Service after the effective date will be automatically adjusted to pay at the updated rate. Providers do not need to contact CCA to initiate this adjustment.

Please see the following link for additional information: https://www.mass.gov/lists/2020-eohhs-administrative-bulletins

Q. How is CCA handling extensions of rate increases, extensions of waivers and/or new COVID regulations?

A. CCA will ensure any new or extended waivers or regulations are adopted when they are released.

Q. Does CCA plan on resuming audit and recovery efforts?

A. In July, CMS released a statement that “CMS expects to discontinue exercising enforcement discretion beginning on August 3, 2020, regardless of the status of the public health emergency.” CCA has resumed audit activity as of October 2020. Providers are required to comply with all audit requests. CCA is actively monitoring for any additional guidance from CMS and EOHHS. Please visit the following CMS link for additional information: https://www.cms.gov/files/document/provider-burden-relief-faqs.pdf

Q. What are the codes for the testing of COVID-19?

A. There are 13 testing codes currently available:

It is noted that U0003 should identify tests that would otherwise be identified by CPT code 87635, but are being performed with these high throughput technologies. It is further noted that U0004 should identify tests that would otherwise be identified by U0002, but are being performed with these high throughput technologies. Finally, it is noted that neither U0003 nor U0004 should be used for tests that detect COVID-19 antibodies. G2023 and G2024 are specific to specimen collection and should not be billed in conjunction with the other testing codes.

HCPCS Codes U0001, U0002 and 87635 will be accepted beginning 4/1/2020 for service dates 2/4/2020 onward. HCPCS Codes U0003 and U0004 will be accepted as of 4/14/2020 for service dates 3/18/2020 onward. HCPCS Codes G2023 and G2024 will be accepted as of 3/30/2020 for services dates 3/31/2020 onward. Please see CMS Fact Sheet for further information.

Codes 86769, 86328, 87426, 86408, 86409, and 86413 relate to tests for antibodies developed during a COVID-19 infection, and will be paid in accordance with applicable Medicare and MassHealth policies.

Q. Has CCA lifted any coding rules?

A. CCA has waived certain coding rules related to the COVID-19 PHE. However, traditional CCI rules will continue to apply and the coding utilized must still accurately describe the care given. Providers should be advised that some denials may remain appropriate throughout the COVID PHE.

Q. The Department of Health and Human Services has issued a blanket waiver under Section 1135 of the Social Security Act. What does this waiver cover?

A. For the most recent coverage of this blanket waiver, please review MLN Matters article SE20011: https://www.cms.gov/files/document/se20011.pdf

Q. Will CCA override timely filing during the COVID-19 public health emergency?

A. Yes. As a result of this PHE, apply the following modifiers to claims for which Medicare payment is based on a formal waiver including, but not limited to, Section 1135 or Section 1812(f) of the Act, effective 3/1/2020. The “DR” (disaster related) condition code for institutional billing, i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form CMS-1450.

Q. Do I need to obtain authorization for COVID-19 services and treatment?

A. No, in order to facilitate immediate access to care for our Members, no authorization or referral requirements are needed for COVID-19 related services or treatment. Providers are still responsible for notifying CCA of such services to ensure appropriate discharge planning. Failure to submit this information will result in a claim denial.

Q. Is there a new ICD-10-CM code for COVID-19?

A. Yes. The CDC issued guidance on 2/20/2020 for COVID-19 related diagnoses. These are contained in our COVID-19 Payment Policy. Please also see CDC Official Coding Guidelines for additional information.

ICD-10-CM coding guidelines with respect to COVID-19 have been updated as of 10/1/2020.

Outpatient settings should follow the ICD-10-CM coding guidelines for confirmed/suspected diagnoses if a diagnosis of COVID-19 is not confirmed.

Inpatient settings do not require confirmation of a positive test result in order to assign U07.1 diagnosis code.

When COVID-19 meets the definition of principal diagnosis, code U07.1 should be sequenced first, followed by the appropriate codes for associated manifestations, except for when another guideline requires that certain codes be sequenced first, such as Obstetrics, Sepsis, or Transplant complications.

DescriptionICD-10-CM Diagnosis Codes
COVID-19U07.1
Suspected COVID-19 diagnosisCode for signs/symptoms*
Pneumonia due to COVID-19U07.1, J18.29
Acute Bronchitis due to COVID-19U07.1, J20.8
Acute Respiratory Manifestations due to COVID-19U07.1 as principal diagnosis, followed by the diagnosis for the acute respiratory manifestation
Lower Respiratory Infection or Acute Respiratory Infection Associated with COVID-19  U07.1, J22
Respiratory Infection NOSU07.1, J98.8
Acute Respiratory Distress Syndrome (ARDS) due to COVID-19  U07.1, J80
Acute Respiratory Failure due to COVID-19U07.1, J96.0X
  Non-Respiratory Manifestations of COVID-19U07.1 as principal diagnosis, followed by the diagnosis for the associated manifestation(s)
Symptomatic with Suspected or Known Exposure (ruled out, or test results inconclusive or unknown)  Signs/symptoms* followed by Z20.828
Asymptomatic with Suspected or Known Exposure  Z20.828
  Screening for COVID-19Previously documented during the initial PHE was Z11.59. Current ICD-10-CM guidelines state during the pandemic screening codes are not appropriate for use. Coding guidance will be updated as new information concerning any changes in the pandemic becomes available.
Asymptomatic with Positive Test ResultU07.1
Personal History of COVID-19Z86.19
Follow-Up Visits After COVID-19 ResolvedZ09, Z86.19
Encounter for Anti-Body TestingZ01.84

*Per ICD-10-CM guidelines, when a definitive diagnosis has not been established, please only assign the diagnosis codes for sign(s)/symptom(s).

Q. Should I send my original claims via paper during the COVID-19 PHE?

A. For the duration of this PHE (or until rescinded), CCA continues to encourage providers to submit claims electronically rather than mailing paper claims, if at all possible. If EDI or web submission is not possible for you, please opt to send via secure fax to (614) 437-1482.

Q. CCA does not accept corrected claims electronically. Can those still be sent via paper?

A. For the duration of this PHE (or until rescinded) please submit all corrected claims via secure fax to (614) 437-1482.

Q. What are the changes to Telemedicine coverage during the COVID-19 PHE?

A. As of 4/3/2020, CMS has increased the ability for providers to care for our Members by relaxing specific regulatory requirements under President Trump’s emergency declaration on a temporary basis, under the 1135 Waiver Authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent feasible, ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform Members of any relevant privacy considerations.

There is a pressing need for virtual benefits to reduce the risk for further spread of COVID-19 by limiting the travel of patients. CCA will honor its current Telemedicine payment policy in addition to the flexibility provided by CMS. In accordance with the relaxed regulations, temporarily, CCA will permit qualified CCA providers to deliver clinically appropriate, medically necessary services to CCA Members via expanded Telehealth (including telephone only and live video). Telehealth Visits, Virtual Check-Ins, and E-Visits will be accepted for dates of service 3/1/2020 onward, and will remain in effect for the duration of the COVID-19 PHE.

Rates of payment for services delivered via Telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods set forth in the applicable regulations. Providers will be able to bill CCA for these services delivered via Telehealth beginning 4/1/2020, for service dates 3/1/2020 onward. When billing professional claims for all Telehealth services with service dates March 1, 2020 onward, and for the duration of the Public Health Emergency (PHE), providers should bill with:

HIPAA: “Effective immediately, the HHS Office for Civil Rights (OCR), will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communication technologies, such as FaceTime, or Skype during the nationwide public health emergency COVID-19.” https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

Q. How should FQHC/RHC services be reported during the COVID-19 PHE?

A. FQHCs and RHCs report by following the guidelines set forth in MLN Matters SE20016.

Virtual Check-Ins

Virtual Check-Ins involving a brief communication (whether via audio and video, audio alone, or via an exchange of health information through video or image) will be payable during this time frame. The patient must verbally consent to these services.

Virtual Check-Ins are only allowed for patients with an established relationship with the provider or certain practitioners.

Below are the coding/billing guidelines for Virtual Check-Ins:

  G2012Brief communication technology-based service (e.g. virtual check-in) by a physician, or other qualified health care professional who can report evaluation & management services, provided to an established patient, not related to a service within the previous seven days and not resulting in a visit within 24 hours. 5-10 minutes of medical discussionTelephone, Audio/Video, Secure Text Messaging, Email, or Patient Portal
G2010Remote evaluation of recorded video and/or image(s) submitted by an established patient (e.g. store and forward) including interpretation with follow up with the patient within 24 business hours or soonest available appointment, not originating from a visit within the previous 7 daysRecorded video and/or image(s)
G0071Payment for communication technology-based services for 5 minutes or more of a virtual (nonface-to-face) communication between a rural health clinic (RHC) or federally qualified health center (FQHC) practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner, occurring in lieu of an office visit; RHC or FQHC onlyRecorded video and/or image(s)

E-Visits

Established patients have the ability to engage in non-face-to-face patient-initiated communications with their provider without traveling to the office and can instead communicate with their provider via a Patient Portal. The patient must initiate and consent to the discussion, and communication may occur over a 7-day period. (FQHC and RHCs bill G0071)

Below are the coding/billing guidelines for E-Visits:

  99421Online digital evaluation & management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
  99422Online digital evaluation & management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11-20 minutes
  99423Online digital evaluation & management service, for an established patient, for up to 7 days cumulative time during the 7 days; 21 or more minutes

Clinicians who may not bill independently evaluation & management services (ex: Physical Therapists, Occupational Therapists, Speech Language Pathologists, Clinical Psychologists) may report the following codes:

  G2061Qualified non-physician health care professional; Online digital evaluation & management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes
  G2062Qualified non-physician health care professional; Online digital evaluation & management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11-20 minutes
  G2063Qualified non-physician health care professional; Online digital evaluation & management service, for an established patient, for up to 7 days cumulative time during the 7 days; 21 or more minutes

Telephone Services

Telephone Services are defined by CPT as non-face-to-face Evaluation & Management (E&M) services provided to a patient using the telephone provided by a physician or other qualified health care professional, who may report E&M services.

Established patients have the ability to engage in non-face-to-face patient-initiated communications with their provider if the telephone service does not end with the patient being seen within the next 24 hours or next available urgent care appointment. If the telephone service is in reference to a service performed within the previous 7 days (either requested or unsolicited patient follow up) or within the post-operative period of a previously completed procedure, then the service is considered part of that procedure and not reported separately.

Below are the coding/billing guidelines for Telephone Services:

  99441Telephone E&M services by a physician, or other qualified health care professional who can report evaluation & management services, provided to an established patient, not related to a service within the previous seven days and not resulting in a visit within 24 hours or soonest available appointment. 5-10 minutes of medical discussion
  99442Telephone E&M services by a physician, or other qualified health care professional who can report evaluation & management services, provided to an established patient, not related to a service within the previous seven days and not resulting in a visit within 24 hours or soonest available appointment. 11-20 minutes of medical discussion
  99443Telephone E&M services by a physician, or other qualified health care professional who can report evaluation & management services, provided to an established patient, not related to a service within the previous seven days and not resulting in a visit within 24 hours or soonest available appointment. 21-30 minutes of medical discussion

Telephone services provided by a qualified non-physician health care professional (Physical Therapists, Occupational Therapists, Speech Language Pathologists, Clinical Psychologists):

  98966Telephone assessment and management services by a qualified non-physician professional provided to an established patient, not related to a service within the previous seven days and not resulting in an assessment and management service or procedure within 24 hours or soonest available appointment. 5-10 minutes of medical discussion
  98967Telephone assessment and management services by a qualified non-physician professional provided to an established patient, not related to a service within the previous seven days and not resulting in an assessment and management service or procedure within 24 hours or soonest available appointment. 11-20 minutes of medical discussion
  98968Telephone assessment and management services by a qualified non-physician professional provided to an established patient, not related to a service within the previous seven days and not resulting in an assessment and management service or procedure within 24 hours or soonest available appointment. 21-30 minutes of medical discussion

Q. What Behavioral Health services are available via telehealth?

A. All services specified in MassHealth Regulations 101 CMR 306.00 et seq. and the outpatient services specified in the following categories of MassHealth Regulation 101 CMR 346.04:

https://www.mass.gov/doc/101-cmr-306-rates-of-payment-for-mental-health-services-provided-in-community-health-centers/download

https://www.mass.gov/regulations/101-CMR-34600-rates-for-certain-substance-related-and-addictive-disorders-programs

Q. How will patients receive their Medications for Opioid Use Disorder (MOUD) in the event of a nurse shortage?

A. EOHHS has considered the potential shortage of nurses able to administer Methadone and Buprenorphine for the treatment of opioid use disorder. In federally certified and Bureau Of Substance Addiction Services (BSAS) licensed opioid treatment programs (OTPs) and Acute Treatment Service (ATS) that hold BSAS licensure and OTP-certified (Certified ATS), pharmacists and pharmacy interns licensed by the Massachusetts board of Registration in Pharmacy and in good standing may administer MOUD in OTPs and certified ATSs pursuant to a qualified practitioner’s order during this public health emergency and pursuant to certain conditions and limitations.

Q. Are LTSS services available via Telehealth during the COVID-19 PHE?

A. Select Adult Day Health, Care Management, and Day Habilitation codes are now available to be billed via Telehealth. Please see the additional resources in the links below on the LTSS services for more information on billing guidelines as these have changed since the initial distribution of information.

See below for Additional Resources and Information

MLN Connects: https://www.cms.gov/files/document/se20011.pdf

MLN Connects:https://www.cms.gov/files/document/se20016.pdf

MLN Matters:  https://www.cms.gov/files/document/se20015.pdf

Coverage and Payments Related to COVID-19: https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf

https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies

CMS COVID-19 Waiver Information: https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers

COVID-19 Telemedicine Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

EOHHS MOUD Order: https://www.mass.gov/doc/march-18-2020-pharmacist-opioid-misuse-disorder-medication/download

EOHHS EMS Ambulance Order: https://www.mass.gov/doc/march-17-2020-ems-care-order/download

MassHealth Managed Care Entity Bulletin 43: https://www.mass.gov/doc/managed-care-entity-bulletin-43-requirements-for-adult-day-health-services-delivered-remotely/download

MassHealth Managed Care Entity Bulletin 52:

https://www.mass.gov/doc/managed-care-entity-bulletin-52-update-to-payment-for-coronavirus-disease-2019-covid-19-vaccine/download

MassHealth All Provider Bulletin 307: https://www.mass.gov/doc/all-provider-bulletin-307-updated-payment-rates-and-authorized-providers-for-coronavirus-0/download

CMS COVID-19 and Monoclonal Antibody Treatment Information: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies

Mass Health LTSS COVID-19:https://www.mass.gov/doc/ltss-provider-updates-for-covid-19/download

ICD-10-CM 2021 Guidelines:https://www.cms.gov/files/document/2021-coding-guidelines.pdf

When Can I Get the COVID-19 Vaccine?: https://www.mass.gov/info-details/when-can-i-get-the-covid-19-vaccine

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