The tricky part is that during the current public health emergency, regulations changed frequently. If hospitals didn’t comply with the specific regulations in effect at the time of claim submission, they could be vulnerable during an audit, according to James Fee, MD, CCS, CCDS, CEO at Enjoin in Eads, Tennessee.
Following are five strategies to help organizations safeguard COVID-19-related reimbursement:
1. Report the correct diagnosis code for COVID-19. The 20% payment increase is a code-based adjustment, said Fee. Prior to April 1, the increase was driven by ICD-10-CM code B97.29. However, as of April 1, that code changed to ICD-10-CM code U07.1.
However, U07.1 has several caveats, and organizations may need to create internal policies for how they will address scenarios for which there is no clear guidance, Fee said. For example, organizations should consider how to handle sequelae and complications of COVID-19 (e.g., pulmonary emboli, deep vein thrombosis or chronic fatigue) that occur weeks or even months after the positive lab test. For example, they may decide to code COVID-19 as an active infection (and thus get credit for the 20% payment increase) or instead to code a personal history of COVID-19 (ICD-10-CM Z86.19).
The most important clue to active infection is whether the organization followed its isolation protocol when treating the patient, Fee said. If the organization didn’t expend additional resources to care for the patient, then it should not receive the additional payment, he said.
2. Focus on MS-DRG accuracy. To report the correct MS-DRG (and thus receive the correct payment increase), organizations must report all clinically valid diagnoses and particularly complications that shift the MS-DRG, Fee said.
They must also sequence COVID-19 according to the most up-to-date ICD-10-CM coding guidelines, according to Stanfill. In essence, COVID-19 should be the principal diagnosis if it meets the definition of such unless the patient has sepsis present on admission or if they are an obstetric patient. Organizations must also be sure to report any and all procedures the patient undergoes (e.g., tracheotomy, ventilation, etc.) because these also drive MS-DRG assignment.
3. Confirm the presence of a positive COVID-19 lab test in the medical record. As of September 1, organizations that receive the 20% payment increase must have a positive COVID-19 lab test documented in the medical record. This test can be performed either during or within 14 days prior to the hospital admission. It can also be performed outside of the organization (e.g., at a pharmacy chain or independent urgent care clinic).
Fee said organizations are meeting this requirement by asking CDI specialists to obtain a copy of the test immediately upon admission for patients who say they tested positive elsewhere or by simply repeating a COVID-19 test for all symptomatic patients on admission.
Stanfill said some of her clients are also sending all cases with a U07.1 code into a queue so a coding auditor can perform a pre-bill second level review to confirm that the positive test is present in the record prior to claim submission.
4. Decline the 20% payment increase, when necessary. Hospitals that diagnose a patient with COVID-19 but don’t have evidence of a positive test result prior to final claim submission can—and should—decline the 20% payment increase and avoid repayments, Fee said. To do so, they must enter a Billing Note NTE02 (“No Pos Test”) on the electronic claim 837I or a remark “No Pos Test” on a paper claim.
5. Perform a 60-day retrospective audit. Medicare permits providers to resubmit claims within 60 days of the date of discharge if they feel additional money is owed (e.g., if documentation clinically supports COVID-19 but no code was assigned).
Prior to September 1, it’s all about clinical validation because there may not have been a positive test to support a COVID-19 diagnosis, Fee said. If organizations are looking to uncover untapped revenue, they must look for clinical evidence of COVID-19 in cases where no code was assigned. Consider these questions:
- Did the patient have respiratory manifestations associated with COVID-19? (e.g., fever, cough, or shortness of breath)?
- Where there any other less common neurologic or gastrointestinal manifestations that could be directly associated with COVID-19?
- Was the patient placed into isolation?
- Did the patient receive any supportive or experimental treatments for COVID-19?
If documentation and treatment support COVID-19, organizations could build the argument that they were underpaid. Even if it’s too late to obtain a copy of a positive COVID-19 test (as required on or after September 1 to obtain the 20% increase), organizations that correctly capture COVID-19 based on clinical indicators and documented in the record will see higher payments due to MS-DRG shifts, Fee said.
Keep in mind that the flip side is that if providers discover overpayments, they must submit a corrected claim which would result in loss of the payment increase and COVID-19-related shifts.