Thursday, September 24, 2020

Is Noridian's Coverage Article for COVID Testing Not Right?


A colleague pointed out that CMS says its table of COVID-containing tests is a comprehensive listing of all tests that contain COVID, and any of them may qualify for special emergency rules regarding a physician's order.   However, CMS adds the table ONLY concerns tests that fall under its physician-order-policy, and this is not a table regarding COVERAGE.   This largely resolves my blog topic below, but I'm leaving the blog intact as it originally appeared.

See the CMS clarification at its (currently 165 page) guidance of COVID special rules, here:

I'm quoted from the 12/8 update, but the particular question in the FAQ is dated back to 6/19.

11. Question: Does the CMS table “COVID-19, Influenza, and RSV Clinical Diagnostic Laboratory

Tests for which Medicare Does Not Require a Practitioner Order during the PHE” list Clinical Diagnostic Laboratory Test codes that Medicare will cover during the PHE? Answer: This table lists codes that, if otherwise covered by Medicare, do not require a treating practitioner’s order as a condition of Medicare payment. The table should not be interpreted as a statement of coverage for the listed codes. There may be some codes for which there are local coverage determinations that non-cover or limit coverage of certain tests. Practitioners and laboratories should check with their local Medicare Administrative Contractor regarding specific questions of coverage. New 6/19/20


I was recently on the CMS website for new articles and by accident I noticed a Noridian article that seems "not right" regarding COVID testing.

The article is A57338, and it's secondary to their master LCD for molecular pathogen testing L37301.  Famously, this legislates against coverage of viral (or pathogen) panels when the test has more than 1-5 pathogens.

Find the A57338 article at CMS here and a cloud copy here.

Very Odd Things Happen

In Article Group 1 codes, the article provides coverage ONLY in limited circumstances, being hospital or emergency rooms, or else, if ordered by an infectious disease specialist.   (If not an infectious disease specialist, you are expected to be in a remote rural location or island).  

But the article then lists codes 87631 (respiratory pathogens any type, 3-5) and CMS COVID codes U0003, U0004.  

That can't be right.  Use of CMS COVID codes like U0003 can't be restricted to hospital and ER only and when ordered by an ID specialist.  (For just one example, CMS explicitly pays for COVID testing collected in nursing homes (here).)   But we all know CMS is supposed to pay for COVID tests ordered in a doctor's office or collected by a Quest.  These CMS COVID codes can't be covered "only when ordered by an ID specialist," or only for inpatients, etc, but the article says so in black and white.

Article Non-Covers Codes Already Explicitly Listed by CMS as Covered

And CMS has an explicit listing of codes COVERED FOR COVID TESTING, and it includes codes NEVER COVERED by Noridian like 87632.   Crazy!  Look here (click to enlarge):

Go figure.  And by the way, I pulled the CMS coverage codes from the CMS website today, so one would assume it's correct. 


Nerd Notes.  When it came out, the article and LCD provide coverage for inpatients, or urgent care/emergency room.  In general, CMS bundles ALL tests for inpatients, and bundles tests OTHER THAN HUMAN GENETICS in the emergency room (hospital outpatient).  So the LCD actually covered molecular pathogen tests in settings where they weren't payable.   (A little different today since CMS has set certain COVID codes to be payable in ER setting).

Nerd Notes.  The Article has been update multiple times, most recently 7/17, 8/13, and 9/16.  However, the revision history section explaining what's new at each step, stops at 7/30.   

For an April blog (not updated) on CMS coverage for COVID here.