Evaluation of the impact of guideline communication from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services among US healthcare providers: COVID‐19 prevention counselling guidance

Abstract Aim To evaluate healthcare provider awareness and uptake of the Centers for Medicare & Medicaid Services (CMS) billing for coronavirus disease 2019 (COVID‐19) prevention counselling and the delivery of prevention counselling to patients awaiting severe acute respiratory syndrome coronavirus 2 test results. Design Cross sectional survey of US‐based healthcare providers in February 2021. Methods Analysis of associations with healthcare provider‐reported awareness of CMS prevention counselling guidance and billing with provider type, specialty, and work setting. Results A total of 1919 healthcare providers responded to the survey. Overall, 38% (726/1919) of providers reported awareness of available CMS reimbursement for COVID‐19 patient counselling and 29% (465/1614) of CMS billing‐eligible providers reported billing for this counselling. Among physicians, those aware of CMS guidance were significantly more likely to bill (58%) versus those unaware (10%). Among RNSights respondents eligible for CMS billing (n = 114), 31% of those aware of the guidance reported billing as compared to 0% of those not aware.

Billing-eligible healthcare providers can be reimbursed by CMS for services that include COVID-19 counselling using existing current procedural terminology (CPT®) E&M codes and payment policies.This counselling and billing initiative by CMS and CDC was intended to encourage medical providers to provide prevention counselling that included isolation and quarantine at the time of SARS-CoV-2 testing.The CDC/CMS initiative was announced and rolled out by CMS in July 2020.Guidance was delivered through CMS' Medicare Learning Network distribution lists, CMS and CDC websites, and direct communication with Medicare's local contractors.These communications are usually amplified by multiple platforms and listservs from physician specialty societies (such as the American Medical Association).The primary objective of this study was to capture information about provider awareness and delivery of CDC-and CMS-recommended patient counselling messages regarding COVID-19.The secondary objective was to determine if providers ordering SARS-CoV-2 testing for patients are billing for COVID-19 counselling services provided.

| Survey development
CDC led the development of a 10-item survey based on CMS and CDC COVID-19 counselling and billing information in November 2020 (Appendix A).We gathered feedback from CDC subject matter experts (SMEs) with knowledge of the delivery of counselling services as part of public health outreach about the appropriateness of survey items.SMEs included physicians, public health analysts, disease investigators, case managers, and contact tracers.We also asked them to take the survey to determine the time needed to complete it and to assess the wording of the items to ensure they were easy to understand and accurately captured the counselling topics.
The estimated time to complete the survey was 3-5 min.

| Survey distribution
In February 2021, CDC partnered with the medical provider membership and resource platforms Sermo (https://www.sermo.com/about/) and RNsights (https://rnsig hts.com/about -us/) to distribute the CDC survey to a convenience sample of United States-based, licensed, practicing healthcare providers.The aim of the survey was to assess provider awareness and delivery of CDC-and CMSrecommended COVID-19 counselling and associated self-reported billing practices.In addition, providers were asked about their general knowledge of the CMS/CDC recommendations on counselling for patients testing for COVID-19, the sources from which they were made aware of counselling recommendations, and the opportunity to bill for this counselling activity.There was no associated compensation or incentive for participation.

| Survey population and distribution
Sermo is a peer-to-peer social platform and healthcare research company membership site that engages with 1.3 million healthcare providers across 150 countries; over 300,000 of these are U.S.based physicians.RNsights is an online platform that hosts a membership of more than 700,000 U.S.-based nurse practitioners (NPs), physician assistants (PAs), and registered nurses and provides engagement opportunities with its members.These survey intervals and cap of 1500 for Sermo reflected the agreement with CDC for a no-cost survey delivery and data collection.The results were two convenience samples of self-selected individuals who volunteered to participate in the survey.

| Data analysis
Descriptive statistics on provider type, specialty, and work setting were performed using SAS (V9.4).The relationship between provider awareness and billing was explored using either the chi-square or Fisher's exact test, as appropriate.Prevalence ratios (PR) were calculated using robust Poisson regression to estimate the probability of billing or providing any counselling based on the location of the worksite.Regression results were adjusted for hospital place of work to discriminate between inpatient and non-inpatient places of counselling, given the time and resource differential between inpatient and outpatient services.

| Ethics approval
This activity underwent CDC ethical board review, received approval (# 0900f3eb81c5e94b), and was conducted consistent with applicable federal law and CDC policy.
There were 423 respondents to the RNsights survey.Four respondents noted no connection to SARS-CoV-2 testing or COVID-19 counselling, so analyses were performed on 419 records.
Among the entire sample, (N = 1919), self-reporting of consistent (Continues) inform their immediate household/contacts that they may wish to be tested and quarantined (70%); (4) review locations and people the patient may have been in contact with in the past 2 weeks (46%); (5) inform patients that if they test positive for COVID-19, they will likely be contacted by a public health worker (58%); (6) advise pa- tients to 'answer the call' from a public health worker to provide a list of people they have been with for contact tracing purposes (51%); and (7) discuss services that might help the patient to successfully isolate or quarantine at home (50%) (Figure 1).
Among physicians responding to the Sermo survey, those working in hospitals were less likely to report providing any counselling as compared to providers working in outpatient settings (PR 0.78/0.86= 0.91, 95% CI 0.86, 0.96).Billing for COVID-19 counselling by hospital providers was reported more often as compared to physicians in outpatient worksites, although these results were not significant (PR 33.55/29.37= 1.14, 95% CI 0.97, 1.34).perience can be considered when developing evaluation methods (Kamb et al., 1996;Omura et al., 2018;Petersen et al., 2007;Searight, 2018;Shen et al., 2019;Wolff et al., 2010).Counselling to address mental health concerns such as fear and anxiety associated with COVID-19 has been identified as an important and unmet need (Costanza et al., 2021;Nagata et al., 2022).However, the limited willingness of patients to participate in interviews and provide information on contacts reduces the prevention benefit of contact tracing (Lash et al., 2021) b RNsights survey allowed for multiple responses for worksite.

TA B L E 1 (Continued)
encounters that include SARS-CoV-2 testing may be able to influence patients to engage with health department-delivered case investigation and contact tracing and comply with timely prevention efforts, including isolation and quarantine, to reduce transmission.

| Strength and limitations
The results from this survey identify opportunities to educate healthcare providers and administrators on public health   (Romano et al., 2021;Smith et al., 2021).

| CON CLUS ION
Activities such as increased communication and education to improve provider awareness the and delivery of counselling may result in patient behaviours that prevent SARS-CoV-2 transmission, reduce the burden of COVID-19, and save lives.Ongoing efforts to guide and support healthcare providers in delivering prevention counselling might help stem the transmission of SARS-CoV-2 and other communicable infections.
such as self-isolation and quarantine, notifying household contacts, and encouraging cooperation with public health COVID-19 case investigation and contact tracing (Centers for Medicare & Medicaid Services, 2020b.Counselling check list; Centers for Medicare & Medicaid Services, 2020c.Provider Q&A; Centers for Medicare & Medicaid Services, 2020d.Talking points for providers; Centers for Disease Control and Prevention, 2019a.Contact tracing; Centers for Disease Control and Prevention, 2019b.Key steps to take while waiting for your COVID-19 test result).CMS provided guidance to physicians on including time spent counselling patients in selecting the appropriate code level of the visit using existing evaluation and management (E&M) codes for Medicare and Medicaid reimbursement for COVID-19-related counselling time.
Survey distribution was restricted to U.S.-based providers.Inclusion criteria for receipt of the survey were: patient care providers within general practice and medical specialties, including physicians, NPs, PAs, and nurses.The following specialties were excluded from survey distribution: hospital administrators, radiologists, ophthalmologists, dermatologists, pathologists, and laboratorians.All responding healthcare providers were included in frequency analyses of awareness and delivery of COVID-19 counselling.Only CMS billing-eligible healthcare providers (physicians, physicians' assistants, and NPs) were included in the frequency analyses of billing.The survey administered through Sermo was disseminated via email to 5442 physicians on 1 February 2021 and closed on 1 March 2021 (4 weeks).The Sermo survey response was capped at 1500 respondents.The survey administered through RNsights was launched via email link to 440,000 recipients on 3 February 2021 and closed on March 5 (4 weeks).Two email reminders were sent during the survey period.
The relatively new advance care planning CPT code and its utilization are examples of how CMS has adopted a payment policy and providers have responded with increased reporting of counselling services.Advance care planning (CPT code 99497) services largely consist of counselling and care planning related to specific topics of advanced disease management.The utilization of this CPT code has increased from over 600,000 Medicare claims in 2016 to over 1,800,000 claims by 2019 (Palmer et al., 2021).Similarly, knowledge of the CDC's and CMS's recommendations may enhance a provider's ability to deliver COVID-19 prevention counselling to patients.As of 13 December 2021, there were 20,211 unique web visits to the CMS announcement for COVID-19 counselling reimbursement, 5, 125 web visits to the CMS provider COVID-19 counselling checklist, and 1003 unique visits to the CMS webpage for provider Q & A on CMS reimbursement for COVID-19 counselling.CDC promotes publicprivate partnerships that include healthcare provider outreach, virtual education sessions and communication activities (Centers for Disease Control and Prevention, 2021c.Public-private partnerships and CDC; Centers for Disease Control and Prevention, 2021a.CDC's COVID-19 partner calls).These have been used to improve healthcare provider and partner awareness of various aspects of COVID-19 care and prevention, including case investigation, contact tracing, and vaccination.Working in partnership with public health personnel, providers may influence the participation of people with COVID-19 and their contacts with public health investigations and contact tracing.CDC modelling estimates suggest that prompt isolation of people with COVID-19 can significantly reduce transmission (Centers for Disease Control and Prevention, 2021b.Prioritizing COVID-19 contact tracing mathematical modelling methods and findings).
Healthcare providers can play a key role not only in identifying and treating COVID-19 but also in providing critical information to patients that can slow the spread of SARS-CoV-2.This evaluation of provider delivery of COVID-19 counselling identified opportunities to improve the knowledge and consistent delivery of CDC-and CMSrecommended prevention messages related to isolation and contact tracing.Providers also have the opportunity to deliver other key prevention strategies, such as the importance of obtaining a COVID-19 vaccine.They may be further encouraged to perform COVID-19 counselling consistent with recommendations if they are aware of and use CMS billing and reimbursement options.This may be especially relevant at this stage in the COVID-19 pandemic, where there is a need for healthcare providers to emphasize the benefits of vaccination (Centers for Medicare and Medicaid Services., 2021.CMS COVID-19 vaccine page for providers).Counselling of Medicaid clients is especially important given the association of lower socioeconomic status and other demographic factors commonly found in this population with higher risks of COVID-19 morbidity Description of healthcare provider respondents of CDC survey, Sermo, and RNsights (N = 1919).
COVID-19 counselling (responses 'always' or 'frequently') was reported for the recommended counselling topics regardless of awareness of billing and reimbursement: (1) review the signs and symptoms of COVID-19 (74%); (2) discuss the need for immediate isolation, even before test results are available (70%); (3) advise patients to TA B L E 1