CMS Updates Medicare Billing Rules for 20% Add-On COVID-19 Payment

Claims eligible for the 20 percent add-on payment for COVID-19 hospitalizations will now have to have a positive laboratory test documented in the patient’s medical record, according to recent Medicare billing updates from CMS.

For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.

In an MLN Matters article from earlier this week, CMS explained that a COVID-19 laboratory test must be performed either during the hospital admission or prior to the hospital admission and must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with guidelines from the Centers for Disease Control and Prevention (CDC).

“For this purpose, 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,” CMS explained in the article.

“For example, a copy of a positive COVID-19 test result that was obtained a week before the admission from a local government-run testing center can be added to the patient’s medical record,” the agency stated. “In the rare circumstance where a viral test was performed more than 14 days prior to the hospital admission, CMS will consider whether there are complex medical factors in addition to that test result for purposes of this documentation requirement.”

The new Medicare billing requirement will apply to admissions occurring on or after September 1, 2020.

Early on in the pandemic, the Coronavirus Aid, Relief and Economic Security (CARES) Act allowed hospitals to collect an additional 20 percent in Inpatient Prospective Payment System (IPPS) operating payments for discharges that contain the ICD‑10‑CM diagnosis code U07.1 for COVID-19.

More recently, the extension of the national public health emergency for COVID-19 continued the availability of the 20 percent add-on payment in addition to regulatory flexibilities and waivers for COVID-19 care.

In order to protect Medicare program integrity, CMS is now requiring a positive COVID-19 laboratory test on all claims eligible for the add-on payment.

“CMS may conduct post-payment medical review to confirm the presence of a positive COVID-19 laboratory test and, if no such test is contained in the medical record, the additional payment resulting from the 20 percent increase in the MS-DRG relative weight will be recouped,” the federal agency stated.

Hospitals that diagnosis patients with COVID-19 but cannot demonstrate a positive test result for the novel coronavirus can decline the add-one payment at the time of claim admission to avoid a potential repayment, CMS said.

The hospitals will have to contact its Medicare Administrator Contractor to notate the claim with an internal claim processing code.

CMS also announced earlier this week that it will resume all routine inspections for Medicare and Medicaid-certified providers and suppliers.

On-site revisit surveys, non-immediate jeopardy compliant surveys, and annual recertification surveys were previously suspended to prioritize infection control and immediate jeopardy situations during the public health emergency.

CMS is now directing its agents and state survey officials to resume the routine inspections to ensure patient safety and quality of life for patients. The federal agency also provided guidance on resolving enforcement cases that were on hold during the survey prioritization changes.

“At President Trump’s direction, CMS has worked closely with states to complete focused infection control surveys of virtually all nursing homes in the country in just a few months,” CMS Administrator Seema Verma said in the announcement. “These surveys fortified healthcare facilities around the country to prepare for and implement actions to prevent transmission of the virus and provided indispensable insight into the situation on the ground. As CMS resumes some survey and enforcement activities that were previously put on hold, the health and safety of America’s patients will always be our top priority.”

Additionally, CMS will temporarily expand the desk review policy to include all noncompliance reviews except for immediate jeopardy citations that have not been removed.