Attachment A: NYS Medicaid Billing Guidance for COVID-Positive Only Facilities

• Attachment A is also available in Portable Document Format (PDF)

Billing Guidance

Nursing Homes approved to operate a COVID-Positive Only Facility will receive a new rate letter for up to six new rate codes. To qualify for the enhanced rate effective January 1, 2021 for the treatment of COVID-19 persistently positive patients, your Nursing Home must meet the conditions set forth in the Dear Administrator Letter for such billing. These rate codes correspond with existing per diem nursing home rate codes.

Table 1: Rate Code Crosswalk

Current Rate Code Billed	Rate Code Description	Corresponding COVID-19 Rate Code
3810	Medicare Ineligible, SNF	5550
3812	Medicare Part B Eligible, SNF	5551
3838	Medicare Part D Eligible	5552
3839	Medicare Part B & D Eligible	5553
2863	Medicare Ineligible, Hospital Based	5554
2862	Medicare Part B Eligible, Hospital Based	5555

For the period the individual is positive for COVID-19, Nursing Homes must bill the COVID-19 rate code corresponding with the rate code for which the individual is currently eligible.

These rate codes are limited to the period that the individual is positive for COVID-19. Once testing negative, Nursing Homes must bill their current, non-enhanced rate codes. No rate enhancement will be authorized for any presumed positive COVID-19 cases, only lab-verified cases of COVID-19.

If the enhanced rate code is appropriate across two months, Nursing Homes are instructed to bill two claims, one up to the last date of the month, the second beginning on the first date of the next month. Nursing Homes may choose to bill more frequently, but the billing should not include dates from two months.

If an individual tested positive prior to January 1, 2021 and the illness extended past January 1, 2021, the enhanced rate codes would only be eligible from January 1, 2021 and beyond.

eMedNY is currently developing an evolution project to allow the 50% enhanced rate codes to occur with the cash assessment. Until that project is completed, Nursing Homes may identify that billings for rate code 3836 may deny. Nursing Homes are encouraged to track these denials. At the time the project is completed, DOH will coordinate with Nursing Homes to ensure appropriate reimbursement. Nursing Homes are reminded to maintain documentation to support all billing claims (medical necessity) and retain a copy of the fully executed Memorandum of Understanding with the Department for the appropriate retention periods.

To ensure the denial occurs for the cash assessment rather than the enhanced per diem rate, DOH strongly recommends Nursing Homes bill the COVID-Positive Only Facility per diem first.

If there are any questions related to this guidance, please contact the eMedNY call center at (800) 343-9000.