CMS Guidance: Reporting Claims for COVID-19 Testing in the T-MSIS Claims Files

This guidance specifies state reporting expectations for Transformed Medicaid Statistical Information System (T-MSIS) claims data for COVID-19 testing and testing-related services for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing. Coronavirus Disease 2019, or COVID-19, is a respiratory disease caused by a novel coronavirus.^[1] The U.S. Secretary of Health and Human Services, Alex M. Azar II, declared a public health emergency as a result of confirmed cases of COVID-19 in the United States. The declaration is retroactive to January 27, 2020.^[2] This document provides guidance to states to report COVID-19 services in the T-MSIS Claims files.

Section 6004(a)(3) of the Families First Coronavirus Response Act (FFCRA) added Section 1902(a)(10)(A)(ii)(XXIII) to the Social Security Act (the Act).^[3] During any portion of the public health emergency period beginning March 18, 2020, this provision permits states to temporarily cover uninsured individuals through an optional Medicaid eligibility group for the limited purpose of COVID-19 testing. Such medical assistance, as limited by clause XVIII in the text following Section 1902(a)(10)(G) of the Act, includes: in vitro diagnostic products for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, and any visit for COVID–19 testing-related services for which payment may be made under the State plan. For the purposes of this eligibility group, please reference the COVID-19 FAQs on implementation of Section 6008 of the Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security (CARES) Act for the definition of an uninsured individual.^[4] States can claim 100 percent FMAP for services provided to an individual enrolled in the COVID-19 testing group. The 100 percent match is only available for the testing and testing-related services provided to beneficiaries enrolled in the new COVID-19 testing group (and for related administrative expenditures).

While not directly applicable to Medicaid, the FFCRA (section 6001) defines testing-related services for group health plans and health issuers as “Items and services furnished to an individual during health care provider office visits (which term in this paragraph includes in-person visits and telehealth visits), urgent care center visits, and emergency room visits that result in an order for or administration of an in vitro diagnostic product described in paragraph (1), but only to the extent such items and services relate to the furnishing or administration of such product or to the evaluation of such individual for purposes of determining the need of such individual for such product.”^[5] Though not necessarily applicable to all Medicaid programs, Medicare uses HCPCS/CPT modifier “CS” to identify COVID-19 testing and testing-related services that are exempt from cost-sharing.^[6]

As states begin providing COVID-19 testing and testing-related services to uninsured individuals who receive limited Medicaid coverage for COVID-19 testing, states must accurately report this information in the T-MSIS Claims files. Without uniform reporting, it is difficult to analyze COVID-19 diagnostic products and testing-related services and expenditures. In addition, as things are changing rapidly, states are encouraged to periodically review the COVID-19 FAQs published by the Centers for Medicare and Medicaid Services.^[7]

To address the completeness and accuracy of reporting services for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing and testing-related services, CMS has provided the following guidance to report services and expenditures in the T-MSIS Claims files. For current Medicaid and CHIP beneficiaries, states should map services and expenditures in the T-MSIS Claims files to the valid values for BENEFIT-TYPE, PROGRAM-TYPE, and TYPE-OF-SERVICE that would be used if the services weren't specifically for COVID-19 testing or COVID-19 testing-related services (for instance, using laboratory services). In addition, states who previously implemented the new T-MSIS values for COVID-19 reporting of claims for current Medicaid and CHIP beneficiaries will not need to resubmit their claims given this guidance update. States should make this change moving forward with their T-MSIS Claims files for existing Medicaid and CHIP beneficiaries. For uninsured individuals, it’s important for states to submit the new TYPE-OF-SERVICE, BENEFIT-TYPE, and PROGRAM-TYPE valid values as far back as is applicable to the uninsured population. Some states may need to fix and resubmit for claims for uninsured individuals.

There are three data elements in the T-MSIS Claims files that states should use to report COVID-19 diagnostic products and testing-related services: BENEFIT-TYPE (CIP268, CLT218, COT209, CRX148), PROGRAM-TYPE (CIP129, CLT079, COT065, CRX055), and TYPE-OF-SERVICE (CIP257, CLT211, COT186, CRX134). Table 1 shows the changes to the valid values for these data elements. These changes will be incorporated into the T-MSIS data dictionary at a future date but should be implemented by states immediately.

Table 1. T-MSIS Data Dictionary new valid values and descriptions to capture COVID-19 diagnostic products and testing-related services for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing (to be implemented by states immediately)

There are data elements captured at both the header and line level on the Claims files that should be reported for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing and testing-related services. States should ensure that there is consistency across these data elements for COVID-19 reporting. For example, a claim for a COVID-19 test should be reported with TYPE-OF-SERVICE “136” and BENEFIT-TYPE “107” at the line level and PROGRAM-TYPE “17” at the header level of the claim.

• CLAIM-HEADER-RECORD- IP/LT/OT/RX- CIP00002/CLT0002/COT00002/CRX00002
  • PROGRAM-TYPE (CIP129, CLT079, COT065, CRX055): A value of “17” should be reported for any COVID-19 diagnostic product that is administered during any portion of the emergency period, beginning March 18, 2020, or COVID–19 testing-related services for which payment may be made under the State plan. PROGRAM-TYPE “17” should always be reported at the header level for claims for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing and testing-related services.
• CLAIM-LINE-RECORD-IP/LT/OT/RX- CIP00003/CLT00003/COT00003/CRX00003
  • TYPE-OF-SERVICE (CIP257, CLT211, COT186, CRX134):
    • A value of “136” should be reported for any COVID-19 diagnostic product that is administered during any portion of the emergency period, beginning March 18, 2020, to an uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testing-related services.
    • A value of “137” should be reported for any COVID–19 testing-related services provided to an uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testing-related services for which payment may be made under the State plan.
  • BENEFIT-TYPE (CIP268, CLT218, COT209, CRX148):
    • A value of “107” should be reported for any COVID-19 diagnostic product that is administered during any portion of the emergency period, beginning March 18, 2020, to an uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testing-related services.
    • A value of “108” should be reported for any COVID–19 testing-related services provided to an uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testing-related services for which payment may be made under the State plan.

CMS recognizes that states have worked with their billing/policy staff to make changes to T-MSIS to report COVID-19 testing and testing-related services. Further COVID-19 guidance about other data elements such as XIX-MBESCBES-CATEGORY-OF-SERVICE (CIP270, CLT224, COT211, CRX150) and XXI-MBESCBES-CATEGORY-OF-SERVICE (CIP271, CLT225, COT212, CRX151) may follow. CMS has also updated validation rule logic in the Operational Dashboard to accept new CPT, HCPCS, ICD-10 and any other national standard codes used to identify COVID-19 related services.

Table 2 below provides suggested mapping of relevant procedure codes to program type, type of service, and benefit types codes. The codes below are provided as an initial starting point for procedure codes that would be expected to be reported for testing and testing-related services. States may also consider diagnosis codes in their mapping. Please note that states are not limited to only the procedure codes identified in Table 2 for testing and testing-related services if your state has identified additional services codes.

Table 2. Suggested mapping of new COVID-19 T-MSIS valid values and procedure codes for uninsured individuals who receive limited Medicaid coverage for COVID-19 testing