Continuing Confusion Clouds CS Compliance

During this week’s Monitor Mondays broadcast, Ronald Hirsch, MD, vice president at R1 RCM, reminded listeners how confusing all the waivers and flexibilities associated with the COVID-19 pandemic have been, while noting that what is more amazing is that the confusion hasn’t stopped.

The latest confusion, Hirsch said, relates to the use of the CS modifier for visits during which a COVID test is ordered or administered, to indicate that the service is 100-percent covered. After three months of confusion, the Centers for Medicare & Medicaid Services (CMS) finally released a list of HCPCS codes that are eligible to have the CS applied in an update to MLN Matters, SE20011. And as Hirsch has reported here in the past, the only codes that are eligible are visit codes. The CS modifier cannot be applied on the line for the CT scan or EKG or any other testing done at the time of the visit.

He went on to clarify that this applies to Medicare only. For group and individual plans, the law specifies 100-percent coverage for the visit, and all items and services furnished during the visit.

“It’s different, and that’s obviously confusing. Not only is that confusing, but CMS seems to have left Q3014, the originating site fee, off of the eligible code list for outpatient hospitals – but they did include G0463, the facility fee, on the list,” Hirsch said. “Furthermore, the list of eligible codes for use by physicians includes the Q3014. It remains unclear why Q3014 is not on the outpatient hospital list, and it is likewise unclear when a physician would charge the originating site fee.”

To make things more uncertain, Hirsch reported that the CMS transmittal gives no instruction to the Medicare Administrative Contractors (MACs) about what to do with claims for which the CS was improperly applied and the provider was already paid at 100 percent.

“Will they automatically recoup the 20 percent and call it a done deal?” Hirsch asked. “But then how do supplemental plans know they are now obligated to pay the balance? What if the patient had not yet paid their deductible when they had that visit, and CMS covered it at 100 percent, but now the patient met their deductible with other services?”

Hirsch continued by asking if CMS will just recoup the whole amount, and make the provider resubmit a corrected claim. And finally, he asked, what are patients going to say when they get that surprise bill, months after their visit, where they were told that everything was 100-percent covered?

While the publication of this list is welcome, Hirsch said, the remaining lingering questions will continue to lead providers down a rocky road in ensuring smooth claim submission and processing.