Oncology & Hematology Coding Alert

Meet this specific set of criteria to waive cost-sharing on eligible services.

As summer trudges onward, COVID-19 is impacting states initially less affected than hot spots like New York and New Jersey. While you may have the coding fundamentals down pat, you don’t want to neglect clinical circumstances that warrant the use of modifier CS (Cost-sharing for specified covid-19 testing-related services that result in an order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency).

Refresher: With the introduction of the Families First Coronavirus Response Act (FFCRA), Medicare is waiving cost-sharing for patients that meet a specific set of COVID-19 testing criteria during their evaluation and management (E/M) visit. While this is great news for individuals and families affected by COVID-19, coders and billers must follow the correct protocol in order to make sure these claims are submitted properly. That means getting a firm grasp on what’s needed to append modifier CS to your E/M claims.

Bank on this set of 6 FAQs for all the most pertinent information you will need on modifier CS reporting.

FAQ #1: What is modifier CS used for?

According to the Centers for Medicare & Medicaid Services (CMS), the implementation of the Families First Coronavirus Response Act (FFCRA) “waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services.” This means that for COVID-19 testing-related services, cost-sharing in the form of co-pays and deductibles is waived. Physicians will receive 100 percent of payment for modifier CS-appended claims. In addition to appending the modifier to the respective claim, CMS advises that “you should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services.”

FAQ #2: Do you need to administer/order a specific test to use CS?

Modifier CS may be appended to E/M claims that result in the administration or ordering of any of the following lab tests:

• 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: While these services will most typically be furnished/ordered, there are a few other tests that qualify for modifier CS, including code range U0003-U0004 and code 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])). Furthermore, antibody lab testing should also qualify for modifier CS, when applicable.

FAQ #3: What E/M services qualify for modifier CS?

There are a wide range of E/M service codes that you may append with modifier CS so long as the components of the visit meet the criteria. Some of these services include:

• Office and other outpatient services,
• Hospital observation services,
• Emergency department (ED) services, and
• Nursing facility services.

With respect to oncology you’ve got to consider the use of modifier CS for current telehealth visits in addition to in-person visits when your respective city and state lifts stay-at-home orders. For a patient telehealth visit that involves the provider assessing the patient’s symptoms and concluding that a COVID-19 diagnosis is warranted, modifier CS is appropriate to append so long as the provider submits an order for the patient to receive one of the eligible lab tests.

FAQ #4: Is modifier CS only applicable to face-to-face visits?

Modifier CS is applicable for use in clinical scenarios involving face-to-face visits and telehealth visits. Obviously, a COVID-19 test will not be administered during a telehealth visit, but a referral for a test may be made, which qualifies the telehealth visit E/M code for modifier CS.

Which payment systems qualify for modifier CS?

Cost-sharing will be waived with modifier CS for a qualifying E/M service to any of the following:

• Hospital outpatient departments paid under the Outpatient Prospective Payment System (OPPS),
• Physicians and other professionals under the Medicare Physician Fee Schedule (MPFS),
• Critical access hospitals (CAHs),
• Rural health clinics (RHCs), and
• Federally qualified health centers (FQHCs).

FAQ #5: Do commercial payers allow modifier CS?

First, it’s important to point out that Medicare Administrative Contractors (MACs) will accept claims with modifier CS appended. As for commercial payers, the answer may vary. For instance, CIGNA will waive cost-sharing on telehealth claims with modifier CS and the appropriate ICD-10-CM code, depending on the status of the patient. Check the respective commercial payer policy for guidance on when you may append modifier CS to eligible claims.

Advice: “It’s crucial to read the guidelines for your payers before submitting claims,” advises Marie Popkin, CPC, CMCS, BSM, ProFee Auditor at HCCS HIM Services in Fort Myers, Florida.

“It’s easier and cheaper to do your research on the front end rather than on the back. I recommend to even screenshot the guidelines on the date you are filing — as the guidelines are constantly changing. You will collect the patient portion as per the payer’s instructions.

Remember, you can call your patient in advance and show the printout of the benefits to the patient — and even mail the patient a copy if needed. Furthermore, remember that CMS states you can waive cost-sharing fees, so if modifier CS is not applicable, you still may waive cost-sharing amounts for federal health care program beneficiaries,” details Popkin.

FAQ #6: Can you append modifier CS to diagnostic scans that result in a COVID-19 lab test order?

Modifier CS is applied only to the select list of E/M services with which a provider orders or administers a COVID-19 lab test. If an oncologist performs and/or interprets an imaging scan and concludes that a COVID-19 test should be ordered to rule out the virus, you should not append modifier CS to the imaging service code.