News: Positive COVID-19 test required to qualify for additional 20% payment

In a recent Medicare Learning Network (MLN) Matters article, CMS announced that it will update COVID-19 policies for inpatient prospective payment system (IPPS) hospitals, long-term care hospitals (LTCHs), and inpatient rehabilitation facilities (IRFs) due to provisions of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Specifically, the MLN Matters article provides updates to the section of the CARES Act applying to IPPS hospitals.

Previously, section 3710 of the CARES Act allows for increasing the weighting factor of the assigned DRG by 20% for a patient diagnosed with COVID-19 and discharged during the public health emergency period. Discharges of a COVID-19 diagnosis must be identified with the following ICD-10-CM codes:

• B97.29, Other coronavirus as the cause of diseases classified elsewhere, for discharges occurring on or after January 27, 2020, and on or before March 31, 2020.
• U07.1, COVID-19, for discharges occurring on or after April 1, 2020, through the duration of the COVID-19 public health emergency period.

For the updated COVID-19 policies, CMS states that “to address potential Medicare program integrity risks, effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record.”

Positive tests results must be from using a viral test that are consistent with Centers for Disease Control and Prevention guidelines and can be performed either before or during hospital admission.

A viral test performed within 14 days of hospital admission is allowed to be manually entered into the patient’s record in order to satisfy this documentation requirement. For example, a copy of a positive COVID-19 test obtained a week before admission from a government-run testing center can be added to the medical record.

CMS states that they will continue to apply an adjustment factor to increase the MS-DRG relative weight that would otherwise be applied by the 20% when determining IPPS payments for discharges reporting diagnosis code U07.1. CMS also says, however, that they may conduct post-payment medical reviews to confirm the presence of a positive COVID-19 test, and if no test is documented in the medical record, the additional 20% payment will be recouped.

Editor’s note: The MLN Matters article can be found here. To read all of ACDIS’ coverage of the COVID-19 pandemic, click here.