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CMS clarifies rules for U0005 COVID add-on payment

When CMS announced its intent to reduce payments for high-throughput COVID-19 tests next year while offering providers a path to be made whole if they met new turnaround time targets, several questions arose concerning how the agency intended to monitor its new requirements. Now, some clarification has been offered as to how CMS expects providers to determine whether they’re eligible for the add-on payment.

To review, the amended Administrative Ruling (CMS 2020-1-R2) lowers the base payment amount for COVID-19 diagnostic tests run on high-throughput technology to $75 beginning Jan. 1, 2021. However, Medicare will then make an additional $25 add-on payment (U0005) to laboratories for a COVID-19 diagnostic test run on high throughput technology if the laboratory:

  • Completes the test in two calendar days or less, and
  • Completes the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month.

In a recently updated FAQ, CMS clarified a test is eligible to be coded for the U0005 add-on payment if more than 50 percent of a lab’s COVID-19 tests for the calendar month previous to the test’s date of service (DOS) were “completed” within two calendar days of collection. For example, if a test DOS is Nov. 10, then whether or not a lab could use the add-on code would be determined by its turnaround times for Oct. 1-31. If 51% or more of those tests were completed within two calendar days, then all COVID-19 tests completed using high-throughput tech in the month of November are eligible for the payment boost (as long as the test in question was also completed within two calendar days of collection).

“Completed,” according to CMS, means the results of the test are finalized and ready for release.

So, while CMS appears set to leave it up to labs to determine initially whether or not they’re meeting requirements for the add-on payment, you can bet this will be an area that is monitored closely throughout 2021.

If you have questions about how to remain compliant while navigating these new rules, feel free to reach out to us directly for a free consultation.


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