Johns Hopkins Advantage MD will pay for the COVID-19 vaccine and its administration (including approved booster doses), without cost sharing, beginning January 1, 2022 for beneficiaries enrolled in their plans. Please go to the CMS Covid-19 website for more information on vaccine administration and related topics.
Please refer to the COVID 19 Testing, Treatment and Vaccination Reimbursement Policy for information regarding coding and reimbursement for COVID testing, treatment and vaccinations.
Health care providers will receive the vaccines from the federal government. Fee for Service Medicare is paying for vaccine administration for Medicare beneficiaries, not Advantage MD or any Medicare Advantage plan. Please bill the CMS Medicare Administrative Contractor (MAC) for all charges for administering COVID-19 vaccines to Advantage MD members. The MAC will reimburse claims for Medicare beneficiaries with no member copayment, coinsurance or deductible for dates of service in 2020 and through 2021. For more information, visit the CMS COVID-19 Insurers Toolkit.
- Any COVID-19 vaccine-related claims for Medicare beneficiaries that are submitted to Advantage MD will be denied, and health care professionals will be directed to submit the claims to the MAC.
The following additional testing codes have been added:
Effective April 10, 2020, during the Public Health Emergency:
- 86328: Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
- 86769: Antibody testing using multiple-step method; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
Effective April 14, 2020, during the Public Health Emergency:
- U0003: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R.
- U0004: 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R.
Effective March 1, 2020, during the Public Health Emergency:
- G2023: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source.
- G2024: Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source. These codes are billable by clinical diagnostic laboratories.
Effective Feb. 4, 2020:
- Testing for COVID-19 is covered with an in-network or out-of-network provider.
- Members will have no cost-sharing (copayments, coinsurance and deductibles) for COVID-19 testing and the associated medical visit (office or other outpatient services; hospital observation services, emergency department services; nursing facility services; domiciliary, rest home, or custodial care services; home services, and online digital evaluation and management services) which results in the administration of a COVID-19 test or an order for such test, but only to the extent the services are related to the COVID-19 test.
- Use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing wavier for COVID-19 testing-related services.
- Prior authorizations and other utilization management requirements are waived for COVID-19 testing and the associated medical visit.
- Reimbursement for CMS codes: U0001 or U0002 and AMA code 87635. Modifier QW should be used with codes U0002 and 87635.
- Medically-necessary testing and treatment at an out-of-network facility will be covered at in-network benefit level.
- Members can be reimbursed for filling prescriptions at an out-of-network pharmacy; cost shares would still apply at in-network benefit level.
- Early refill restrictions waived on prescription for at least 30-day supplies.
- Telemedicine: Rural-only requirement waived for real-time audio/video services; the waiver temporarily eliminates the requirement that the originating site must be a physician’s office or other authorized health care facility and allows Medicare to pay for telehealth services when beneficiaries are in their home or any setting of care.
- Existing patient requirement lifted. Services can now be furnished to new and existing patients.
- Behavioral Health services can be provided via telemedicine but IOP is not a Medicare covered service.
- Licensed clinical social worker services, clinical psychologist services, physical therapy services, occupational therapist services, and speech language pathology services can be paid for as Medicare telehealth services.
- Same authorization requirements apply for telemedicine as for face-to-face visits; special authorization not required because service being delivered via telemedicine.
- Same copayments/coinsurance apply for telemedicine as face-to-face visits.
- Telemedicine used for the testing and treatment of COVID by in-network and out-of-network providers is covered.
- Removal of frequency limitations:
- A subsequent inpatient visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every three days (CPT codes 99231-99233);
- A subsequent skilled nursing facility visit can be furnished via Medicare telehealth, without the limitation that the telehealth visit is once every 30 days (CPT codes 99307-99310)
- Critical care consult codes may be furnished to a Medicare beneficiary by telehealth beyond the once per day limitation (CPT codes G0508-G0509).
- For non-traditional telehealth services with dates of service on or after March 1, 2020, bill with the Place of Service (POS) equal to what it would have been in the absence of a Public Health Emergency, along with a modifier 95, indicating that the service rendered was performed via telehealth.
- This a temporary enhancement to the POS traditionally used for billing telehealth. Even with this temporary change, providers may continue to bill POS 02 for traditional telehealth services and it will continue to be accepted.
- CMS is not requiring the “CR” modifier on telehealth services.
- There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.
- Review this complete list of all Medicare telehealth services, which includes additional temporary codes in response to COVID-19.
The following telemedicine code has been added:
- G2025: For telehealth distant site services furnished between July 1, 2020, and the end of the COVID-19 Public Health Emergency, RHCs and FQHCs will use an RHC/FQHC specific G code, G2025, to identify services that were furnished via telehealth. Reimbursement $92.
Virtual Check-Ins & E-Visits
- Existing patient requirement lifted. Services can now be furnished to new and existing patients.
- Licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech language pathologists can provide e-visits. (HCPCS codes G2061-G2063).
- A broad range of clinicians, including physicians, can now provide certain services by telephone to their patients (CPT codes 98966 -98968; 99441-99443).
- The following table illustrates the respective payment rates to the physician or other practitioner; they vary based on the practice setting.
|HCPCS||Descriptor||Office-based Payment Rate to the Professional||Facility-based Payment Rate to the Professional|
|99421||Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes||$15.52||$13.35|
|99422||Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes||$31.04||$27.43|
|99423||Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes||$50.16||$43.67|
|G2061||Qualified non-physician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes||$12.27||$12.27|
|G2062||Qualified non-physician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes||$21.65||$21.65|
|G2063||Qualified non-physician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes||$33.92||$33.56|
|G2012||Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion||$14.80||$13.35|
Please refer to the Current Emergencies page on the CMS website for coding and billing questions and general COVID information.
For coding and billing questions please refer to the Medicare Telehealth FAQs from March 17, 2020 for details.
Temporary Suspension of Medicare Sequestration for Advantage MD Plans
Effective Dates: May 1, 2020 through December 31, 2020
Explanation of Change(s):
Due to the recent passage of the federal stimulus act, Medicare Sequestration (the two percent cut to payments for Medicare fee-for-service claims, enacted in 2013) will be temporarily lifted beginning on May 1, 2020 and ending on December 31, 2020. This change applies to all Maryland Johns Hopkins Advantage MD plans.
The language from the bill is as follows:
- Section 3709. Adjustment of Sequestration. During the period beginning on May 1, 2020 and ending on December 31, 2020, the Medicare programs under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) shall be exempted from reduction under any sequestration order issued before, on, or after the date of enactment of this Act.