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

Updated 8/27/2020

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.

COVID-19 Testing and Related Services

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 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.

Updated August 27, 2020: Yesterday, CMS released a list of HCPCS/CPT codes that require the CS modifier in order for FQHCs to be reimbursed for services.  The list currently may only be accessed by clicking on the link inside this education release in the “Claims, Pricers, and Codes” section. In addition, they clarified that any claims submitted with the CS modifiers for services not on this list will be returned for correction and resubmission. Please note that this list of services pertains to those which are for COVID-19 testing and testing related services and for preventive telehealth services only.  The CMS MLN SE20011 was also updated to reflect this change.

Preventive Telehealth Services

Updated July 6, 2020: CMS MLN SE20016 was updated to include the requirement that preventive health services provided via telehealth must now be billed with the CS modifier. These preventive health services are those which had previously been without cost share, but now if they are provided via telehealth the CS modifier will apply.  The FQHC Preventive Services Chart may be found by clicking this link. Any services that are not specifically related to COVID-testing or the testing itself or are not preventive health services provided via telehealth are subject to any applicable cost-sharing.

  • January 27 – June 30, 2020 when telehealth preventive services cost sharing is waived, these services will be billed with the HCPCS Qualifying Visit PPS G Code, G2025 and the CS and 95 Modifiers on those claim lines. A non-FQHC PPS Qualifying Payment code does not require a modifier.
Revenue Code Health Center Code Modifiers
052X FQHC Specific Payment Code N/A
052X FQHC PPS Qualifying Payment Code CS, 95 (required)

 

052X G2025 CS, 95 (required)

 

  • As of July 1, 2020, these services would be billed with the G2025 and the CS Modifier.
Revenue Code Health Center Code Modifiers
052X G2025

 

CS (required) 95 (optional)

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

FQHC Preventive Services Chart

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-Preventive-Services.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 SE20016 issued April 30, 2020, updated July 6, 2020

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

CMS MLN SE20011 issued March 15, 2020, updated August 26, 2020

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

CMS Outreach and Education August 27, 2020 – CS Modifier code list

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-08-27-mlnc#_Toc49329805

CMS Outreach and Education 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 (continuously updated)

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