The Interim Final Rule (IFR) released 4/30/2020 recognized the need for reimbursement for COVID -19 assessment and specimen collection. Pre-public health emergency (PHE), specimen collection was usually considered part of the office or outpatient evaluation and management (E&M) service.  The Centers for Medicare and Medicaid Services (CMS) realized early on during the PHE, that testing was critical and not all patient’s have existing provider relationships.   CMS reviewed the available CPT and HCPCS codes to identify an appropriate code that would support assessment of symptoms and take specimens for COVID-19 laboratory testing.  CPT code 99211 (office or outpatient E&M of an established patient, that may not require the presence of a physician or other qualified health care professional) was the most rational choice. However, 99211 clearly states “of an established patient” which would limit the expected use of the code.  Therefore, the IFR allowed CPT code 99211 to include new patient’s during the PHE.  The IFR also eased the restrictions of direct supervision, allowing the requirement to be met through virtual presence of the supervising physician or practitioner (within state scope) using interactive audio and video technology through the PHE.  These concessions would allow reimbursement for new and established patient’s to be assessed and have specimen collected for testing of COVID-19 by auxiliary clinical office or outpatient staff furnished “incident to”.

A few things to remember about “incident to”.  Taking into account the modifications the IFR makes to “Incident to”, allowing 99211 to be reported for new patients and direct supervision provided via interactive audio/video technology, it does not give any further exceptions for other components required for “incident to” reimbursement.  “Incident to” as described in 42 CFR 410.26 and further described in section 60 of Chapter 15 Covered Medical and other Health Services in the Medicare Benefit Policy Manual 100-02. also includes the following requirements:

  • Auxiliary staff must be employed by the practice (e.g. W2, leased employee or an independent contractor),
  • The services and supplies are commonly furnished in a physician’s practice, and
  • Part of an integral though incidental part of the service of a physician or practitioner (within state scope) in the course of diagnosis or treatment of an illness or injury.

The last component of “incident to” means there needs to be direction from the physician or practitioner of the service to be provided by the auxiliary staff.  The IFR does not give clear advice as to how this component may be met. It has been suggested that providers should implement a written protocol for auxiliary staff to assess symptoms of COVID-19, and when present obtain the appropriate sample for laboratory testing.  The protocol should include specific documentation requirements to support services were performed as directed in the written protocol and the physician or practitioner was available via interactive audio/video during the entire encounter.

On the most recent CMS “Office Hours” call (5/26/2020) it was clearly indicated that if a patient received any E&M service on the same day as 99211, the specimen collection is not eligible for additional reimbursement as it continues to be considered part of the E&M service.

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