CMS Issues Clarifications on How to Obtain Additional Coverage during the Pandemic

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The Centers for Medicare & Medicaid Services (CMS) continues to clarify instructions on authorized Medicare coverage waivers and modifications due to the COVID-19 public health emergency (PHE) through a Medicare Learning Network (MLN) publication.[1]

In a CMA Alert last month, the Center for Medicare Advocacy presented a case study that described the circumstances under which a beneficiary may qualify for an additional 100 days of coverage in a skilled nursing facility (SNF) due to the PHE.[2]

CMS has recently confirmed that “beneficiaries who do not themselves have a COVID-19 diagnosis may nevertheless be affected by the PHE.”[3] CMS clarified that if “the beneficiary is receiving the very same course of treatment as if the emergency had never occurred”, the beneficiary would not qualify for additional SNF days.[4] However, the qualification states that a “determination basically involves comparing the course of treatment that the beneficiary has actually received to what would have been furnished absent the emergency. Unless the two are exactly the same, the provider would determine that the treatment has been affected by – and, therefore, is related to – the emergency.”[5]

CMS asks providers to work with the respective Medicare Administrative Contractors (MACs) to deliver any documentation needed to establish that the COVID-19 emergency applies for the benefit period waiver.[6] CMS further instructs providers to utilize the Health Insurance Prospective Payment System (HIPPS) code that was billed when the beneficiary reached the end of the SNF benefit period.[7] CMS documents specific provider billing instructions in order to process a claim for an additional 100 benefit days in the SNF.[8]

The CMS MLN also outlines detailed instructions for providers to bill for PHE related waivers and modifications other than SNF services including the following services: inpatient psychiatric, inpatient rehabilitation, long term care hospital, critical access hospitals, neoplastic disease hospital, durable medical equipment (and prosthetic, orthotics and supplies)(DMEPOS), replacement prescription fills, community mental health centers, some end stage renal disease services, face-to-face requirements for national and local coverage determinations, some respiratory, home anticoagulation management, infusion pump and therapeutic continuous glucose monitor national and local coverage determinations, DMEPOS prior-authorization, Part B prescription drug refills, and signature requirements for proof of delivery.[9]

Beneficiaries and providers have expressed a significant amount of confusion on how to bill for these PHE-related waivers and modifications. The MLN should help to clarify those steps and help to obtain Medicare coverage for beneficiaries who qualify for services.


[3], page 11 of July 8, 2020 version of the MLN.
[4] Id.
[5] Id.
[6] Id., page 12.
[7] Id.
[8] Id., pages 12-13.
[9] Id., pages 2-6.