Medicare COVID-19 Testing for Nursing Home Residents and Patients

The Centers for Medicare & Medicaid Services (CMS) instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID-like symptoms in an outbreak.

Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.

For the full Medicare Learning Network article, CLICK HERE.

CMS Releases FAQs on Nursing Home Visitation

The Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on visitation for nursing home residents that provides clarifications and considerations including:

Visitation for compassionate care situations

  • CMS clarifies compassionate care situations are not exclusive to end-of-life situations.   An example is provided explaining a resident who was living with their family prior to being admitted to the nursing home may experience trauma due to the change in their environment and sudden lack of family.  Therefore, this may qualify as a compassionate care situation.

Outside visits

  • CMS encourages creative means of connecting residents and families including visitation outside of the facility while ensuring all actions for preventing COVID-19 transmission are followed.

Communal activities

  • Residents (without COVID-19 symptoms) may eat in the same room with social distancing.
  • Group activities may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask.

Steps for reopening to visitors

  • Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction.
  • CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when the following criteria are met:
    • No new onset of COVID-19 in the nursing home for 38 days
    • No staff shortages
    • Adequate supplies of PPE and essential cleaning and disinfection supplies
    • Adequate access to testing for COVID-19
    • Referral hospitals have bed capacity on wards and ICUs

Factors to consider regarding visitation

  • CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders.

To access the complete FAQs document from CMS’ Current Emergencies webpage, CLICK HERE.

Recovery and Rehabilitation Following COVID-19

As research and data collection regarding the recovery from COVID-19 grows, valuable information from research studies identifying correlations between contracting the virus and other acute medical complications, as well as the increased risk of readmission to the hospital, is clear. Current data suggests that patients hospitalized for COVID-19 are at increased risk for blood clots, strokes, heart and lung damage, speech and swallowing difficulties due to prolonged intubation, and neurological impairments.  It is our job to have a heightened awareness of potential complications associated with COVID-19 and communicate any findings to the interdisciplinary team (IDT).  With proper notification of subtle observed symptoms, the IDT can work together to minimize the side effects of COVID-19 and decrease the need for rehospitalization, consequently avoiding delayed recovery, increased potential for exposure to other contagions, and development of further complications.

Recovery is not only needed for those who have survived COVID-19; recovery, although different, is also needed for those who did not contract the virus but find themselves dealing with side effects from the modification of routines and activities in an effort to combat the spread of COVID-19. Current data shows that older adults who have not contracted the virus are seeing physical and psychosocial effects due to social distancing that result in deconditioning, increased effects of chronic disease, and reduced functional capacity. Facilities can provide ways to keep residents active while still maintaining social distancing guidelines. To thwart the effects of isolation and inability to see family, facility staff can provide technology, such as Facetime, to allow for residents to check in with their loved ones. Another consideration would be to reach out to family members and encourage them to send pictures and care packages to brighten the residents’ day.  We must ensure minimal impact to those who have made the skilled nursing facility their home by increasing opportunities for social and physical activities while maintaining precautions and social distancing during the COVID-19 pandemic.

COVID-19 has touched everyone, either directly or indirectly, and the effects of the virus may linger for an indefinite amount of time.   However, through increased communication among the IDT, we can potentially aid in speeding up the recovery process and in minimizing the risk of rehospitalization.   Additionally, through increased social and physical opportunities, our residents who have not contracted COVID-19 can explore alternative ways to stay connected and physically active.  Through the actions of a proactive interdisciplinary team, we can assist all our residents in achieving functional and quality outcomes allowing for enhanced quality of life.

Honking for Hugs #CareNotCOVID

With the restrictions on visitors, several communities across the country have gotten creative showing appreciation for patients and residents by coordinating “Honk for Hugs” events in a reverse parade fashion.

Forest Hills Care and Rehabilitation, Broken Arrow, OK

The Forest Hills Care and Rehabilitation team in Broken Arrow, OK participated in two community parades, which allowed the patients and residents to see friends and family from a safe distance.

Let’s recognize the team:

Rachel Blanchard DOR
Dianna Sunday PT
Rebecca DeVilliers OTR
Chelsea Holmes OTR
Shannon Pinson SLP
Kelsey Farragher SLP
Saundra Fite PTA
Tara Stephenson PTA
Katie Forler PTA
Candice Ertman PTA
Michelle Kellam COTA
Kimberly Luu COTA

Cottonwood Creek Healthcare Center, Richardson, TX

Cottonwood Creek Healthcare Center in Richardson, TX held a Honk for Hugs event with patients and residents. The patients and residents had so much fun!

CareCore at Westmoreland, Chillicothe, OH

CareCore at Westmoreland’s therapy team in Chillicothe, OH decorated and had patients participate in a “Honk for Hugs” event where the community showed how much they cared for the facility patients and residents.

Let’s recognize the team:

Angie Nartker PT
Kelly Davidson SLP
Crystal Steele PTA
Amanda Karr PTA
Jill Burton COTA
Penelope George PTA/DOR

When Will We Begin Seeing Medical Review Audits Following the COVID-19 PHE?

While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following

“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.

  1. Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
  2. Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post­ payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.

Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”

Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.

CMS Releases Toolkit for Nursing Homes

CMS has released a toolkit to aid nursing homes, governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. Access the toolkit here.

The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency.

The toolkit is comprised of best practices from a variety of front line health care providers, governors COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

View the full press release from CMS here. The toolkit can be accessed here.

CMS Issues Guidance to Ensure the Safe Reopening of Nursing Homes

After President Trump revealed Guidelines for Opening Up America Again on May 18, the Centers for Medicare and Medicaid Services (CMS) announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country.  State leaders are encouraged to collaborate with the state survey agency and local health departments to develop a plan on how these criteria should be implemented.

CMS recommends that decisions on relaxing restrictions in nursing homes be made with careful review of the following facility-level, community, and state factors:

  • Case status in community
  • Case status in the nursing home(s)
  • Adequate staffing
  • Access to adequate testing
  • Universal source control
  • Access to adequate personal protective equipment (PPE) for staff
  • Local hospital capacity

Reliant’s Real Time Memo on this topic can be accessed here.

CMS’ guidance can be accessed here.

The Frequently Asked Questions (FAQ) document can be accessed here.

or questions or concerns related to this memo, please email the DNH Triage Team.

Connection Through Video Chat

As the country continues to take a proactive, preventative approach to reduce the spread of COVID-19, social distancing and visitor restrictions in long-term care challenge us to use alternative means for connecting patients, family members/responsible parties, and long-term care staff.  On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised) stating:

“In lieu of visits, facilities should consider offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.)”1

When choosing to use video communication, the US Department of Health and Human Services provides guidance regarding which video communication platforms are safe to use and which are not. For example, FaceTime and Skype* are classified as non-public facing remote communication products while TikTok, Facebook Live, and Twitch are public-facing products.  Public-facing products are not acceptable to use. 

When video chatting, be mindful of the following:

  • Obtain proper authorization for use or disclosure from the resident/patient/responsible party.
  • Make reasonable efforts to ensure others, not authorized to participate in the video chat, cannot hear the discussions.
  • Ensure other patients are not in the background of the video chat to prevent unauthorized use or disclosure of that individual.
  • Confirm the party answering the video chat is the appropriate party before proceeding with discussions.
  • Be sure when ending video chat that it successfully ends so that other conversations or videos are not accidentally seen or overheard.

*FaceTime and Skype means of communication are not supported by HIPAA regulations outside of the current healthcare emergency. The Office of Civil Rights states:

“Health care providers may use popular applications that allow for video chats, such as FaceTime and Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.” 

1 https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf

2https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Implementation Strategies: Trauma-Informed Care During the COVID-19 Pandemic

The COVID-19 pandemic introduces unique considerations related to patient-specific care plans, the execution of trauma-informed care (TIC) and the implementation of protocols to prevent disease transmission allowing for the continued provision of quality care.  In order to incorporate TIC, each patient’s unique history, specifically those relevant to the current environmental demands, should be addressed with strategic care planning. 

Interdisciplinary teams must help alleviate the unintended consequences of social isolation and source control strategies (i.e. face mask use) while in pursuit of infection control.  Now, more than ever, we must be familiar with our residents and newly admitted patients, their histories, potential triggers and preferences in order to develop and employ patient-specific TIC successfully. 

Consider the following strategies:

  1. Determine the health literacy of each resident/patient and provide education concerning infection control and prevention at their level of understanding to the diminish potential for new trauma
  2. Adapt protocols as necessary and modify care plans accordingly to prevent re-traumatization.
  3. Provide patients reassurance as often as necessary that protocols in place are in their best interest.
  4. Address needs for a sense of normalcy by developing new routines, roles, and habits. 
  5. Mitigate the psychosocial effects of isolation through creative implementation of activities to promote socialization and engagement.
  6. Utilize technology to facilitate connections with family and friends, when possible.

There are no shortages of avenues for success with TIC, but communication is critical for them all.  At its core, TIC requires communication with the patient and their designated representative for historical knowledge and care plan updates. It takes each member of the interdisciplinary team offering specific insight resulting from their familiarity with the patient, to develop a thorough and comprehensive care plan for the individual that accomplishes preventing traumatization or re-traumatization.  Do not diminish the explicit value each member brings as their contribution may very well be the one to enable positive patient outcomes. 

Will Your Documentation Stand Up in a Post-Pay Review Following the COVID-19 Pandemic?

The current SNF coverage decisions, under the COVID-19 Section 1135 Waivers, allow providers to render skilled services to LTC residents, considered “skilling in place.” It is important to note that the previous requirements for skilled care need as defined in Chapter 8, Section 30 of the Medicare Benefit Policy Manual remain unchanged.

The quality of our documentation should not change regardless of payer; however, when an 1135 waiver is evoked, extensive care should be taken to document the reasoning for the initiation of the Part A benefit (e.g., change in condition) and why the qualifying event (e.g., 3 day hospital stay or wellness period) was waived. According to CMS FAQs regarding the waivers, if “continued skilled care need…is unrelated to the COVID-19 emergency, then the beneficiary cannot renew his or her SNF benefits.”

Relation to the emergency may include:

  • early hospital discharge due to resource need or
  • avoiding hospital transfer due to exposure risk.

Documentation is our defense when under review—as we continue to provide care to our residents, educate nursing and therapy to demonstrate the complexity, sophistication, and medical necessity of the services provided throughout the episode of care. Our services have a positive impact on many areas of the patient’s life. It’s important that the work we do with each of them carries over onto paper to fortify defensibility following this pandemic and to ensure our patients continue to have access to quality care. 

Review the Medicare Part A waive memo here.

Review CMS FAQs for 1135 waivers here. (SNF Services may be found on pages 34-35)

AHCA Waiver Application Decision Making Flowcharts:

Coronavirus Scams

There are increasing reports of scams and phishing attempts referencing COVID-19. These attacks many times appear as innocent emails looking for assistance or providing information regarding the COVID-19 crisis. Bad Actors are taking advantage of this crisis to prosper or do damage.  Their criminal actions are becoming more and more sophisticated and look very official as though coming from government agencies and health organizations.

It is critical to remain vigilant with all email correspondence and websites, but particularly those referencing COVID-19 updates, maps, donations, notifications etc.

To avoid becoming a victim, follow the guidelines below:

  • Never click on links or open attachments within unexpected emails.
  • If you receive a suspicious email appearing to come from a legitimate organization such as CDC, WHO, FEMA etc., confirm its legitimacy.  Make sure links direct you to the official site by hovering over the link.  Report suspicious email to your company’s Information Security Department.
  • If you visit a website or receive a pop-up window directing you to a phone number for support desk assistance, DO NOT call the number, instead contact your company’s Information Security Department.
  • Never share your password with anyone.

Trends noted to date include:

  • Malicious Websites – sites referencing coronavirus or COVID-19 in the URL. Thousands of new websites have recently been registered to distribute malware when the user accesses the site.
  • Spam – emails trying to grab your attention to sell information or goods now in high demand such as masks, hand sanitizers, COVID-19 drugs, etc.
  • Phishing – emails posing to be from legitimate organizations such as Center for Disease Control (CDC), the World Health Organization (WHO), Federal Emergency Management Agency (FEMA), etc. These emails contain malicious links, and some are collecting personal information.
  • Fake Charities – emails and websites asking for donations for studies, healthcare professionals, victims, or other activities related to COVID-19
  • Fake internal HR or IT communications such as coronavirus surveys pretending to be from your company’s HR or IT department – these sites are attempting to obtain your User ID and password or other personal information.
  • Fake notification of infection – beware of emails reporting you have been exposed to an infected individual, particularly ones asking for personal information to proceed.

 Always Think Before You Click.

COVID-19: Answering the Call

Because our patients and residents typically are older, often have underlying chronic medical conditions and live in a community together, they are at the highest risk of being affected by COVID-19. During this unprecedented time, our residents rely on the members of their interdisciplinary team to ensure that their health and safety needs are met.

With a team approach of collaboration, communication and demonstration of the value and essence of our skilled professions, we will answer the call to protect this vulnerable population in the pursuit of No Patient Left Behind. Whether it’s clinical considerations in the recovery wake of a COVID-19 diagnosis or ensuring they are supported to continue to attain and maintain the highest level of practicable function within this modified environment, nursing facilities are equipped to meet the needs of the residents who call our facilities home.

Each member of the interdisciplinary team – including therapy, nursing and administrative team members – has specific skills that can help meet the residents’ needs. Collaborative efforts to integrate each team member’s contributions allow for greater positive impact on the care provided.  Timely and effective communication of changes in function should be ongoing between nursing and therapy to identify emerging conditions and potential symptoms of COVID-19.  Each patient is unique and requires screenings relative to their specific diagnoses, history and risks. It is our imperative to ensure dignity, quality of life and the highest level of independence possible. Members of the care team have been empowered to own their distinct role in resident-centered advocacy, which ultimately leads to successful outcomes.

Any member of the interdisciplinary team can lead the advocacy efforts for each resident by observing changes in the resident’s ability, ensuring timely notification, developing a resident-specific plan of care and thoroughly planning for the next level of care. Care delivery must be adapted by team members to occur in bundled sessions with enhanced in-room treatment techniques. By working together, we can help curb the potential anxiety and psychosocial effects perpetuated by a world in pandemic and affirm that no patient is left behind.

Medical Review Audits Suspended

Reliant has worked closely with the National Association for the Support of Long Term Care (NASL) to raise awareness of the activity associated with Medicare’s medical review process during this pandemic, including pre-pay targeted probe and educate (TPE) activity and post-pay recovery audit contractor (RAC) reviews. At this time, Novitas, First Coast and CGS have suspended TPE activity until further notice. Our contacts indicate current pre-pay TPEs will be released and paid in the coming weeks.

According to an FAQ released on 3/30/2020, CMS indicates suspension of most Medicare Fee-For-Service (FFS) medical reviews during the emergency period due to the COVID-19 pandemic. The FAQ states that both pre-payment medical reviews such as the reviews for TPE and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractors (SMRCs) and Recovery Audit Contractors (RACs) are suspended for the duration of the Public Health Emergency (PHE).

The FAQ also notes that “no additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic.” Current post-payment review by the MACs, SMRCs, and RACs will be suspended and released from review as well. CMS is suspending these medical review activities for the duration of the PHE, but could conduct medical reviews “during or after the PHE if there is an indication of potential fraud.”

Medicare Advantage Plans Prior Authorization Suspended

In response to the COVID-19 pandemic, Medicare Advantage plans are issuing temporary suspensions in prior authorization requirements for post-acute settings and revising policies to improve patient access to care.

UnitedHealthcare (UHC) is suspending prior authorization requirements for post-acute settings through May 31, 2020, with the waiver applying to skilled nursing facilities (SNFs), long-term care facilities (LTCFs), and acute inpatient rehabilitation (AIR).  In addition, UHC will reimburse physical, occupational and speech therapy telehealth services provided by qualified health care professionals when rendered using interactive audio/video technology, emphasizing state laws and regulations apply.

Cigna has indicated a similar suspension for commercial and Medicare Advantage plans, noting it will make it easier for hospitals to transfer patients to long-term acute-care hospitals (LTACHs) and other sub-acute facilities to help manage the demands of increasingly high volumes of COVID-19 patients

Medicare Accelerated and Advanced Payments Now Available

On March 28, 2020, the Centers for Medicare & Medicaid Services (CMS) expanded the current Accelerated and Advance Payment Program to a broader group of Medicare Part A providers and Part B suppliers. This program expansion, which includes changes from the recently enacted Coronavirus Aid, Relief and the Economic Security (CARES) Act, is one way CMS is working to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic and ensures the nation’s providers can focus on patient care.

Eligibility qualifications state the provider/supplier must:

  • Have billed Medicare for claims within 180 days immediately prior to the date of signature on the provider’s/supplier’s request form
  • Not be in bankruptcy
  • Not be under active medical review or program integrity investigation
  • Not have any outstanding delinquent Medicare overpayments

Medicare will start accepting and processing the Accelerated/Advance Payment Requests immediately. CMS anticipates that the payments will be issued within seven days of the provider’s request.   

Access CMS’ step by step guide for eligibility and processes here.

COVID-19 Medicare Waivers

CMS is empowered to take proactive steps through 1135 waivers and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are available: 

  • Three-Day Stay Waiver: CMS is waiving the requirement at Section 1812(f) of the Social Security Act for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) stay, providing temporary emergency coverage of SNF services without a qualifying hospital stay for those who need to be transferred as a result of the effect of a disaster or emergency.
  • SNF Part A 100-Day Benefit Waiver: For certain beneficiaries who recently exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period.
  • MDS Completion and Submission Waiver: CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.

Read the Coronavirus 1812(f) waiver.

New Targeted Plan for Healthcare Facility Inspections

On March 23, 2020 CMS released guidance to state survey agencies further prioritizing and suspending most federal and state surveys and delaying revisit surveys for the next three weeks beginning March 20.

CMS has released this survey tool to review infection prevention and control practices. Providers are encouraged to perform a self-assessment utilizing this same tool. Surveyors will review for:

  • Overall effectiveness of the Infection Prevention and Control Program (IPCP) including policies and procedures
  • Standard and transmission-based precautions (with the understanding that certain essential supplies are scarce, and facilities should not be penalized for not having certain supplies if they are unable to obtain them)
  • Quality of resident care practices, including those with COVID-19 (laboratory-positive cases), if applicable
  • Surveillance plan
  • Visitor entry and facility screening practices
  • Education, monitoring and screening practices of staff
  • Facility policies and procedures to address staffing issues during emergencies, such as transmission of COVID-19

Click here for the Survey Prioritization Fact Sheet.

PPE Guidance from CDC and CMS

The CDC issued guidance for optimizing the PPE supply, specifically facemasks, gowns and eye protection, including suggestions on what to do in case of shortages.

CMS recommends reaching out to a health care coalition (HCC) in your area for emergency response assistance. Click here for an interactive map with contact information.

Additionally, AHCA has warned providers to beware of COVID-19 scams selling PPE or other supplies. To aid in differentiation between legitimate businesses and scams, the Federal Trade Commission (FTC) has provided general guidance on COVID-19-related scams.

March Clinical Appeals

Denial Reason Code W7020- NCCI Edit Update

In February, CMS rescinded the National Correct Coding Initiative (NCCI) Edits which restricted the billing of CPT codes 97530 and 97150 on the same day as billing of PT/OT evaluation codes (97161, 97162, 97163, 97164, 97165, 97166) retroactively to January 1, 2020. Nonetheless, many providers have experienced line item denials due to the edit enacted for the short duration. These line item denials are reflected by reason code W7020. To resolve, CMS will be correcting the NCCI edit, beginning April 6, 2020. Medicare Administrative Contractors (MACs) will automatically reprocess claims, without provider action.  When reconciling payments,

  • Review Part B line items for denial of HCPCs 97530 and 97150, in the presence of evaluation codes 97161, 97162, 97163, 97164, 97165, 97166.
  • If line item denials are identified, determine if reason code W7070 is appended.
  • If confirmed, flag impacted claims for review for automatic reprocessing following CMS correction of the edit, beginning April 6, 2020.
  • CMS has indicated provider action is not required.
  • Follow up with your MAC should reprocessing not occur or occur with errors.

SNF Claims Incorrectly Cancelled

From January 26 through February 16, 2020, a software issue caused SNF claims to be incorrectly cancelled with a message that there was no three-day qualifying hospital stay. This issue has been corrected. If your claims were incorrectly cancelled, re-bill them in sequential order to receive payment.

  • Claims need to process in date of service order for each stay for the Variable Per Diem (VPD) to calculate correctly.
  • Submit claims in sequence and wait at least 2 weeks before billing subsequent claims.
  • Some of the affected claims with older dates of service will require a timely filing exception; enter “Resubmission due to non-qualifying stay” in the remarks field.

Click here for more information.