CPT/AMA Announces a New PPE code – But is it Payable?

Some third-party payers have reimbursed and will continue to reimburse providers for this new CPT code; others won’t.

The American Medical Association (AMA) published a new CPT® code on Sept. 8 that accounts for extra provisions to ensure patient and provider safety during a public health emergency (PHE).

The code is effective immediately: CPT 99072 – Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a PHE as defined by law, due to respiratory-transmitted infectious disease.

However, the Centers for Medicare & Medicaid Services (CMS) has weighed in on the new code, and had an announcement of its own. On Oct. 27, it assigned CPT 99072 procedure status “B.” What “B” status means is that the services are considered “bundled.”

Their narrative said the following:

Status “B” means:

• There are no RVUs (relative value units) for this code;
• CMS considers it to be bundled with whatever service was provided that day;
• CMS contractors will not pay for this service;
• Providers may not bill the beneficiary for this service; and
• Issuing an Advanced Beneficiary Notice (ABN/waiver) related to this service is not an option.

Some third-party payers have reimbursed and will continue to reimburse providers for this new CPT code; others won’t.

The CPT Editorial Panel creates CPT codes, but plays no role in developing payment for those codes. CPT also added additional guidance for this service in the way of their CPT   ® Assistant Special Edition: September Update/Volume 30, 2020:

Additional coding guidelines for 99072 include the following:

• The time counted in any other time-based visit or service during the same encounter cannot be counted twice to report this code.
• You do not need to link the code to a particular diagnosis code, such as ICD-10-CM U07.1, COVID-19.
• You may report 99072 with an evaluation and management (E&M) service or procedure, even if You may report 99072 only once per in-person patient encounter, per Provider Identification Number (PIN).

However, with that AMA guidance, many providers and practices have been asking the question, “How are you telling clients to handle the PPE billing, since most payers are not reimbursing for the new 99072 code?”

First, note that as of this writing, there has been no definitive payment for CPT code 99072 by most payers, so it is important that physicians check with their Medicare contractors and insurance carriers for specific guidance. But we have been able to get some reimbursement feedback in our due diligence, and here is what we have found.

Commercial Plan Submissions:

• Blue Cross North Carolina commercial member (fully insured, state health plan, inter-plan program host members) providers can include code 99072 on the claim; however, payment will be considered “incident to” the course of diagnosis or treatment of a condition (i.e. furnished as an integral, although incidental, part of the physician’s personal professional services). As such, it will not be paid separately.
• BCBS of Illinois is approving and allowing $50 for code 99072, but has no contract RVU. They are requiring it to be billed with the physician office visit as a separate line item. Further, they have “retro’d” the coverage to Sept. 1.
• Advocate-Aurora Health Plan announced that for their commercial HMO plans, they will allow $10 beginning Jan. 1, 2021.
• UHC Texas has stated on their website that they will “consider” all reasonable PPE charges up to $15 with the 99072 CPT code.

So we do have some payers willing to pay for this service, outside the usual office visit code. However, it will be up to the medical practices to determine what payers are willing to do that. The dental practices seem to be having better luck with this code, with many dental coverage payers allowing up to $30 per encounter for the PPE expense.

However, it is my thought that the U.S. Department of Health and Human Services (HHS) may have decided that since it gave a big boost to providers via the Coronavirus Aid, Relief, and Economic Security (CARES) Act, it has already paid for the extra costs associated with the COVID pandemic, while complying with the law, and that bundling 99072 as a part of the E&M services is consistent with this position, while protecting Medicare and Medicaid patients from a balance billing barrage.

As you can see, It appears that commercial carriers are choosing to take their own path. It is too bad that AHIP (Association of Health Insurance Providers) does not provide an easy way to inform employers or the public at large what each is doing. It is an opportunity lost.

My advice is to remove 99072 from your chargemaster for all Medicare patients, and on the commercial side, figure out who is paying the extra service prior to submitting the claim, so that the patient isn’t surprised with a balance bill.

Programming Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 a.m. EST.