Waive Cost Sharing on Applicable Claims Using Modifier CS

Waive Cost Sharing on Applicable Claims Using Modifier CS

The implementation of the Families First Coronavirus Response Act waives cost-sharing (coinsurance and deductibles) for COVID-19 testing-related services.  The Act is a bit convoluted (as most Acts are) so the Centers for Medicare & Medicaid Services (CMS) breaks down what it all means for Medicare Part B claims in a special edition of MLN Connects, released on April 7.

Here’s What You Need to Know

The following guidelines pertain to evaluation and management (E/M) services that result in the administration or ordering of COVID-19 lab tests by an outpatient provider, physician, or other providers and suppliers billing under Medicare Part B. This means that, to waive cost-sharing, the E/M visit must result in one of the following COVID-19 lab tests being ordered or administrated:

  • U0001 CDC 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel
  • U0002 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc
  • 87635 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

Note: The American Medical Association released two new testing CPT® codes after CMS published the MLN Connects SE: 86328 and 86769. As such, CMS does not address these codes in the provider education.
CMS further outlines that cost sharing is waived for qualifying E/M services dated March 18 through the end of the public health emergency. This guideline applies to any of the following E/M services, so long as the criteria for the visit is met:

  • Office and other outpatient services
  • Hospital observation services
  • Emergency department services
  • Nursing facility services
  • Domiciliary, rest home, or custodial care services
  • Home services
  • Online digital evaluation and management services

Furthermore, cost sharing is waived for a qualifying E/M service to any of the following:

  • Hospital outpatient departments paid under the outpatient prospective payment system
  • Physicians and other professionals under the physician fee schedule
  • Critical access hospitals
  • Rural health clinics
  • Federally qualified health centers

When to Use Modifier CS

For the aforementioned services billed to their respective payment systems, append modifier CS Cost-sharing for specified covid-19 testing-related services that result in an order for or administration of a covid-19 test on applicable claim lines to identify the service as subject to the cost-sharing wavier for COVID-19 testing-related services. In addition, CMS advises that you should NOT charge Medicare patients any co-insurance and/or deductible amounts for these services.
Providers may also retroactively resubmit applicable professional claims with modifier CS from March 18 and beyond so long as they contact their Medicare Administrative Contractor beforehand. Institutional claims may also be resubmitted with modifier CS appended to receive 100 percent payment.
See the April 7 and April 10 MLN Connects SE for compete details.

Brett Rosenberg

About Has 12 Posts

Brett Rosenberg, MA, CPC, COC, CCS-P, serves as the editor of The Coding Institute’s (TCI’s) Radiology, Otolaryngology, and Outpatient Facility Coding Alerts. He earned his bachelor’s degree in psychology from the University of Vermont in 2011 and his master’s degree in psychology from Medaille College in 2016. Rosenberg is affiliated with the Flower City Professional Coders local chapter in Rochester, N.Y.

12 Responses to “Waive Cost Sharing on Applicable Claims Using Modifier CS”

  1. Barbara Thom says:

    If I understand this correctly, I do NOT need a CS modifier added to a charge for the actual COVID-19 test (U0001 – U0004, 87635) or the specimen collection C9803. Is that correct? Thank you!

  2. Lee Fifield says:

    From the author: Your are correct, Barbara. The CS modifier is appended to an E/M visit that results in the ordering of one of those tests or specimen collections.

  3. Sue Bland says:

    What if the provider is doing the covid test as a precaution? In my instance the patient has had shortness of breath for a couple months and their PCP is requiring the covid test before the patient can be seen. The patient went to a walk in clinic to be assessed and have the test. Would this still be eligible for the CS modifier?

  4. Tracy Kastner says:

    Can you please tell me if we use the CS modifier on the facility claim. Also, does the CS modifier get added to any x-ray or lab (not the COVID test) related to a COVID diagnosis? I code for the facility side and have been getting conflicting information.

  5. Renee Dustman says:

    yes

  6. Renee Dustman says:

    Yes, modifier CS applies to institutional claims. The CS modifier applies to all COVID-19 testing-related services.

  7. Tasha says:

    If I am reading this correctly, the CS modifier is only to be used when the provider orders a COVID test? So in a case where a positive patient presents a few days later for COVID related issues, I would not apply the CS modifier, correct?

  8. Renee Dustman says:

    Per CMS MLN Connects, April 7, 2020, Special Edition:
    Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the Public Health Emergency (PHE); that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes:

    Office and other outpatient services
    Hospital observation services
    Emergency department services
    Nursing facility services
    Domiciliary, rest home, or custodial care services
    Home services
    Online digital evaluation and management services

  9. Demetra McFarland says:

    On professional claims for the reading of the x-rays…do you use the modifier 26 along with the CS modifier

  10. Lee Fifield says:

    Demetra, from the author: You will not apply modifier CS to radiological codes. Only E/M visits. If a provider uses radiological findings during an E/M visit that results in the ordering of a COVID-19 test, then modifier CS is appropriate to append to the E/M code.

  11. Maddie Banerjee says:

    Could somebody please clarify whether we should append – CS modifier to an E/M service that is related to Covid 19? For example if a patient is seen for covid related issues and still has covid but after the testing is done, does that qualify for a CS modifier? We are getting a lot of calls from patients saying that their insurance companies have told them that we should append modifier CS to any covid related issues not just testing related. I would appreciate any help on this one. Thank you.

  12. Renee Dustman says:

    The Families First Coronavirus Response Act (FFCRA) waives cost sharing, both coinsurance and deductible amounts, for Medicare patients receiving COVID-19 testing-related services, as well as testing. The Coronavirus Aid, Relief, and Economic Security Act (the CARES Act) amended the FFCRA to provide a broader range of diagnostic items and services that plans must cover without any cost sharing requirements or prior authorization or other medical management requirements.

    CMS specifically lists these E/M services as included:

    Office and other outpatient services
    Hospital observation services
    ED services
    Nursing facility services
    Domiciliary, rest home, or custodial care services
    Home services
    Online digital E/M services
    CMS states that physicians must notify their MAC and request to re-submit applicable claims for full payment. Institutional claims, including hospitals, CAHs, RHCs and FQHCs must resubmit applicable claims with modifier CS to receive 100% of payment.