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Is CMS changing the way it will reimburse providers for COVID-19 lab tests that utilize high-throughput technology?

Yes. On October 15, 2020, CMS announced that effective January 1, 2021, the reimbursement rate for high throughput COVID-19 laboratory HCPCS codes U0003 and U0004 will be reduced from $100 per unit to $75 per unit. Per a press release, CMS states it believes the new reimbursement rate of $75 per unit is more accurate based on their “assessment of the resources needed to perform those tests”.

However, CMS will reimburse an additional add-on payment of $25 per unit to eligible providers who complete the high throughput COVID-19 diagnostic tests within two calendar days of the specimen being collected. Eligible providers will report new HCPCS code U0005 beginning January 1, 2021 to receive the additional $25 add-on payment. Per CMS, add-on HCPCS U0005 is only eligible to be reported in conjunction with primary HCPCS codes U0003 and U0004. CMS also clarified that a laboratory test is considered “complete” when “the results of the test are finalized and ready for release”.

Per the CMS COVID-19 FAQ on Medicare Fee-for-Service Billing document, the requirements that must be met in order to report HCPCS U0005 are as follows:

“Starting January 1, 2021, laboratories can bill Medicare for the $25 add-on payment using HCPCS code U0005 if:

1) they completed the COVID-19 Clinical Diagnostic Laboratory Test (CDLT) in 2 calendar days or less from the date of specimen collection; and

2) the majority of their COVID-19 CDLTs performed using high-throughput technology in the previous calendar month were completed in 2 calendar days or less for all of their patients (not just their Medicare patients).”

Per updated CMS Ruling, CMS-2020-1-R2, providers will need to keep records to support that the majority of their high-throughput COVID-19 tests were completed within 2 calendar days – for all patients, not just those patients whose primary insurance is Medicare.

“In the event of an audit or medical review, laboratories will need to produce documentation of timeliness based on their performance in the month preceding the month identified by the line date of service for the corresponding CDLT represented by HCPCS U0003 or U0004.”

CMS Press Release, “CMS Changes Medicare Payment to Support Faster COVID-19 Diagnostic Testing”:

CMS COVID-19 FAQ on Medicare Fee-for-Service Billing:

CMS Ruling, CMS-2020-1-R2:

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