CMS REVISES MLN MATTERS SE 20015

Calling all coders!  We wanted to get this out to you as a quick special edition newsletter to keep you informed of the latest CMS payment policy changes for COVID-19 services.

On August 17 CMS published updated payment information regarding COVID-19 policies for acute care hospitals, long-term care hospitals, and inpatient rehabilitation facilities. The update specifically addresses implementation of Sections 3710 and 3711 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

Section 3710 – IPPS Hospitals

The CARES Act increases the weight of the assigned Diagnosis-Related Group (DRG) by 20 percent for an patient diagnosed with COVID-19 who is discharged during the COVID-19 Public Health Emergency (PHE) period.

Claims must contain the following ICD-10-CM diagnosis codes: NOTE that the COVID-19 diagnoses are NOT required to be the principal diagnosis on the claim.

• 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 public health emergency period.

• For discharges on or after April 1, 2020, the ICD-10-CM Official Coding and Reporting Guidelines are at https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf

• For discharges prior to April 1, 2020, the ICD-10-CM Official Coding Guideline – Supplement is at https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf.  

Medicare Program Integrity

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 weight must 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 CDC guidelines. The test may be performed either during the hospital admission or up to 14 days prior to the admission provided the test results are incorporated into the medical record for the specific admission. If the 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.

Providers can expect post-payment audits to confirm the presence of a positive COVID-19 laboratory test.  Absence of a positive test will result in recoupment of the additional 20% payment.

A hospital that diagnoses a patient with COVID-19 consistent with the ICD-10-CM Official Coding and Reporting Guidelines but does not have evidence of a positive test result can decline, at the time of claim submission, the additional 20% payment to avoid the repayment. To do so, the hospital will inform its MAC and the MAC will flag the claim with MAC internal claim processing coding for processing.

Section 3711 – IRFs and LTCHs

Inpatient Rehabilitation Facilities (IRFs) - Intensity of Therapy Requirement

During the COVID-19 PHE, Medicare Part A fee-for-service patients treated in IRFs are not required to receive at least 15 hours of therapy per week.

Long Term Care Hospitals (LTCHs) – Site Neutral Payment Rate Provisions

During the COVID-19 PHE, the CARES Act waives the payment adjustment under Section 1886(m)(6)(C)(ii) of the Act for LTCHs that do not have a Discharge Payment Percentage (DPP) for the period that is at least 50 percent during the COVID 19 PHE period. Under this provision, for the purposes of calculating an LTCH’s DPP, all admissions during the COVID-19 PHE period will be counted in the numerator of the calculation, that is, will be counted as discharges paid the LTCH Prospective Payment System (PPS) standard Federal payment rate. To implement this provision, the claims processing systems will be updated to pay all LTCH cases admitted during the COVID-19 PHE period the LTCH PPS standard Federal rate, effective for claims with an admission date occurring on or after January 27, 2020. In short, Section 3711 provides some financial relief to those LTCHs who suffered a significant decline in admissions during the COVID PHE.

LINKS

For the complete list of coronavirus waivers:  https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers

Review information on the current emergencies webpage at https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page.

If you have questions, your MACs may have more information. Find their websites at http://go.cms.gov/MAC-website-list.

The following articles provide updates to payment policy for COVID-19 claims.

• MM11742 – The article is based on CR 11742 that updates the LTCH Pricer software used in Original Medicare claims processing. The CR also includes new payment policy for the Novel Coronavirus Disease, COVID-19 https://www.cms.gov/files/document/mm11742.pdf

• MM11764 – The article is based on CR 11764 which updates the FY 2020 IPPS Pricer software used in Original Medicare claims processing. It includes new payment policy for individual diagnosed with COVID-19. https://www.cms.gov/files/document/mm11764.pdf