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CMS Revises Guidance on Add-on Payment for COVID-19 Patients

For CFOs, billing staff

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The Centers for Medicare & Medicaid Services (CMS) has revised its guidance on the add-on payment for COVID-19 patients. The guidance states that effective with admissions occurring on or after Sept. 1, claims eligible for the 20% increase in the Medicare Severity-Diagnosis Related Group weighting factor for cases with a COVID-19 diagnosis will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. 

Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with Centers for Disease Control and Prevention guidelines. The test may be performed either during the hospital admission or up to 14 days prior to the hospital admission. CMS notes that 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. Hospitals should carefully review the guidance and educate staff on documentation policies to ensure outside test results are properly documented in the medical record.   

The claims processing system will continue to apply the increase if ICD-10-CM diagnosis code U07.1 (COVID-19) is on the claim. If the diagnosis has been coded consistent with ICD-10-CM coding guidelines, but the hospital cannot document a positive COVID-19 test, the hospital may inform its Medicare Administrative Contractor (MAC) prior to claims submission and the MAC will note the claim with an internal processing code. This will result in the 20% increase not being applied. If the increase is applied and the hospital cannot document a positive COVID-19 test upon post-payment medical review, the additional payment will be recouped.