HCPCS CS Modifier Guidelines Related to COVID-19 Testing for Community Health Centers

By: Lisa Messina, Corporate Compliance Officer

Categories: FQHC, Industry News, PMG Insights Blog

June 25, 2020

The Family First Coronavirus Response Act (FFCRA), which went into effect March 18, 2020, waives cost-sharing (i.e., coinsurance and deductibles) by patients receiving COVID-19 testing-related services, as well as the testing itself. This Act applies to group and individual health plans including Medicare, Medicare Advantage, Medicaid, CHIP, and private payers. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, which became law on March 27, 2020, amended the FFCRA to provide a broader range of diagnostic items and services that plans must cover without cost-sharing by the patient.

CMS has provided interpretation of the cost-sharing waiver rules through newsletters and FAQs referenced in the Research Sources of this blog. CME states that the waiver applies to COVID-19 testing-related services, which are medical visits (in-person or via telehealth*) that:

  • Are furnished between March 18th, 2020 until the end of the COVID PHE;
  • Result in an order for or administration of a COVID-19 test (which can be negative);
  • Are related to furnishing or administering a COVID-19 test or to the evaluation of a patient to determine the need for a COVID-19 test; and,
  • Fall under an office or other outpatient service. CMS lists many other settings that do not apply to health centers.

In short, cost-sharing is waived for office visits that result in the order or administration of the COVID-19 test, or the evaluation of an individual to determine the need for such a test. “COVID-19 related tests” include molecular, antigen, and antibody testing.  The original FFCRA and CARES Act refer to the waiver as being applicable to diagnostic testing and related services. However, the most recent “FAQs about FFCRA” offered by CMS conclude that serological tests (antibody tests) are considered to be included under Section 3201 of the CARES Act that defines COVID-19 testing.

CMS requires that the HCPCS CS modifier be applied to E/M services related to COVID-19 testing, and/or swabbing (if not part of the E/M service), and/or POC testing provided by health centers with a service date of March 18th, 2020 through to the end of the COVID PHE.  The CS modifier is added on the applicable claim lines to identify those services which are not subjected to the cost-sharing waiver.  Patients are not charged any coinsurance and/or deductible amounts for those services.  Any claims submitted without the CS modifier must be resubmitted in order for health centers to collect the cost-sharing amount from the payer that the patient would have made during ordinary circumstances.  Any services that are not specifically related to COVID-testing or the testing itself are subject to any applicable cost-sharing.

PMG’s research shows that commercial payers may have different requirements pertaining to the use of the CS modifier. Clients are encouraged to contact PMG with questions.

Research Sources:

FAQs about FFCRA

https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf

Family First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security (CARES) Act

https://www.hfma.org/content/dam/hfma/Documents/industry-initiatives/fact-sheets/families-first-coronavirus-response-act-cares-act-summary.pdf

CMS MLN April 30, 2020

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

CMS MLN April 7, 2020

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-07-mlnc-se

CMS MLN April 10, 2020 Update to April 7th issue

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-10-mlnc-se#_Toc37418832

CMS COVID-19 FAQS (Updated June 2, 2020)

https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

AAFP COVID-19 Private Payer FAQs

https://www.aafp.org/dam/AAFP/documents/practice_management/COVID-19/payer-faqs.pdf

AAFP COVID-19 Private Payer Table

https://www.aafp.org/dam/AAFP/documents/practice_management/COVID-19/COVID-payers.pdf