Q&A: COVID documentation requirements

CDI Strategies - Volume 14, Issue 44

Q: Can you offer any insight as to how you are handling CMS’ new requirement for documentation of COVID-positive patients stating that the physician needs to document not only that the patient is COVID-positive but include documentation of a positive COVID test result if one was done in the 14 days prior to admission?

A: There is no easy answer for the steps that facilities will need to take to fulfill the new CMS requirement for additional payment for COVID-19 cases. Unfortunately, each facility will need to determine the processes needed to identify positive test results.

Per CMS, “a viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, can be manually entered into the patient’s medical record to satisfy this documentation requirement.”

Although it is not as easy as the CMS statement above, there are a few things that facilities will need to consider when making process decisions to obtain COVID positive test results that were generated from outside the facility:

  1. If the test result was taken in-house, then ensuring that the results are linked to the patient’s record would be needed. This is the easiest scenario.
  2. If the test was taken by an outside facility, health department or other entity, a mechanism to generate the request for the test result will be needed as well as a process for follow up as there may very well be a time delay in receiving the requested information, especially if dealing with health departments that are experiencing a back log of reporting test results (such as Florida).  
  3. Additional questions to think about include:
    1. Will you extend the discharged, not final billed timeframe while awaiting the test results?
    2. Will you re-bill once the positive test result is received?
    3. What happens if the patient refuses to sign an authorization to release the test result from a different organization? 
    4. Will the facility make the decision to retest the patient in house?
    5. How will the facility handle false COVID results when the provider determines that the patient has COVID based on symptoms? 
    6. Will they use the ambiguous CMS process in place for which they will give consideration for these scenarios without a stated turn-around time? Or, will the facility retest the patient internally to avoid long waiting periods that may occur with CMS backlog for reconsideration due to this new requirement? 

One other piece of information to play into these considerations is that the American Hospital Association (AHA) wrote a letter to CMS Administrator Seema Verma on August 26 urging the agency to provide additional flexibility regarding the test documentation requirements.

“This new requirement will put substantial administrative burden on hospitals at a time when they are focusing their efforts and resources on critical patient care,” the letter says. “[W]e urge CMS to allow provider documentation to suffice if the test result is unavailable.”

If you are experiencing administrative burden due to this rule change, you can also write a letter to CMS following the AHA’s lead as this will allow for you to speak specifically to the issues in your facility.

So, stay informed about what industry associations are doing on behalf of hospitals during this time and keep on top of how CMS and other regulatory bodies are acting and reacting. In these COVID times, anything can change at seemingly any moment.

Editor’s Note: Dawn Valdez, RN, LNC, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.

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