Note from the editor: New year, new start

Wednesday, January 13, 2021

by Nicole Votta

The start of a new year is traditionally a chance to get a fresh perspective—something we’re all looking for after the challenges and tragedies we faced in 2020. But changing the date doesn’t wipe the slate clean. In many ways, we’re still tackling the same problems we were last year. Although we need to hold onto those hard-earned lessons and stay committed to our goals and values, we can start the year by taking a fresh look at these familiar issues and orienting ourselves to the past and the future.

For revenue integrity professionals, this means surveying the status of last year’s biggest projects and how they’ll unfold in 2021.


Although the COVID-19 pandemic ushered in few changes to core revenue integrity functions, such as chargemaster maintenance, the furious pace of new codes, coding guidelines, and billing rules meant processes were frequently revised. Revenue integrity professionals were faced with tough questions like whether determining to hold some accounts pending additional information from CMS or whether other accounts should be reviewed and rebilled for services newly approved.

The bulk of CMS’ pandemic-related billing and coding changes may be behind us, but January 1 marked the effective date of what could be among the trickiest: appropriately billing for high-throughput diagnostic COVID-19 test add-on HCPCS code U0005 (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, CDC or non-CDC, making use of high-throughput technologies, completed within two calendar days from date and time of specimen collection).

High-throughput COVID-19 diagnostic tests are reported with the following HCPCS codes:

  • U0003, 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, making use of high-throughput technologies
  • U0004, 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high-throughput technologies


In 2020, the Medicare payment for U0003 and U0004 was $100. For tests dated on or after January 1, the base payment is reduced to $75.

However, laboratories that meet two conditions are able to bill for U0005 to receive an additional $25 payment. First, the laboratory must have completed the majority of their high-throughput COVID-19 diagnostic tests within two calendar days of specimen collection for all patients during the previous month. Second, the particular test being billed must have been completed within two calendar days of specimen collection. In other words, to even consider billing for U0005 in January, you would have had to monitor collection and completion of high-throughput COVID-19 diagnostic test provided to all patients—not just Medicare patients—in December. If 51% or more were completed within two calendar days in December, you may bill for U0005 in January, but only if the test is completed within two calendar days. You’ll also need to gather data throughout this month to determine whether 51% or more of tests conducted in January are completed within two calendar days, allowing you to bill for U0005 on qualifying tests in February.

That’s complex to explain, never mind put into action.

Revenue integrity professionals have reported that their organizations are taking various approaches. Some, after analysis of their particular circumstances, have opted to forgo billing for U0005 altogether. At other organizations, revenue integrity and laboratory staff are working together to build compliant processes and practical workflows. Revenue integrity professionals should keep a close eye on this issue throughout the year. The complexity of the billing rules means that the margin for error is high, making it an obvious target for future audits.

Price transparency

For many revenue integrity professionals, their other major project last year was preparing to comply with CMS’ new, expanded price transparency requirements. This would have been a major ask even in an ordinary year, and some revenue integrity professionals found themselves fitting a year’s worth of work into the last quarter of 2020.

Now that we’ve passed the January 1 effective date, it’s time to evaluate how well hospitals met the requirements. Unfortunately, some hospitals may have missed the mark, Becky Greenfield, partner at Wolfe Pincavage, LLP, in Miami and chair of the Florida HFMA Payor committee, told HealthLeaders.

Greenfield conducted a brief, informal audit of clients, HealthLeaders reported. Although the hospitals had invested significant resources into meeting the requirements, the results weren’t satisfactory.

“I did not see one that was compliant 100% with the rule, as of today,” Greenfield said. “It's a massive undertaking. I think hospitals, in good faith—at least the ones that I've spoken to—are trying to achieve compliance and I think that they will get there. But, as of today, it is not achieved.”

That doesn’t bode well for CMS’ first round of price transparency compliance audits, set to start this month. Revenue integrity professionals need to take a critical look at the information their hospitals have posted and consider whether it truly meets CMS’ requirements. Some hospitals have worked with vendors to develop price estimators and other tools to help them comply, but that’s not a guarantee that the files pass muster. Hospitals are responsible for ensuring that the tools and files they post are compliant. Simply relying on a vendor’s word isn’t good enough.

New perspective

Revenue integrity professionals have their work cut out for them in 2021. There’s still little certainty about the future, but by approaching tasks old and new with a fresh perspective you can find solutions that adapt to circumstances. As always, NAHRI is here to connect you to the information and resources you’ll need to make that happen. Start your year on the right foot with the following resources:

  • Check out the January 2021 issue of the NAHRI Journal for details of the 2021 OPPS and MPFS final rules, an analysis of new price transparency requirements, a fresh take on KPIs, and more.
  • Sign up for the 2021 series of NAHRI’s members-only Quarterly Calls to keep up with association news and expert analysis from revenue integrity leaders.
  • Join a Local Chapter to build your network and swap ideas with peers in your region.
  • Apply for the NAHRI Leadership Council to connect with other revenue integrity thought leaders.


Keep an eye out for additional opportunities throughout the year.

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Revenue Integrity