On August 17, 2020, CMS issued a Medicare Learning Network (MLN) Matters article providing that for admissions occurring on or after September 1, 2020, in order to be eligible for the 20 percent increase in the MS-DRG weighting factor, COVID-19 diagnoses must be documented in the patient’s medical record with a positive COVID-19 laboratory test. Positive tests may be demonstrated using only the results of viral testing (i.e. molecular or antigen), consistent with CDC guidelines.
Section 3710 of the CARES Act provides that “in the case of a discharge of an individual diagnosed with COVID–19, the Secretary shall increase the weighting factor that would otherwise apply to the diagnosis-related group to which the discharge is assigned by 20 percent.” Section 3710 further states that “[t]he Secretary shall identify a discharge of such an individual through the use of diagnosis codes, condition codes, or other such means as may be necessary.”
CDC coding guidance for COVID-19 encounters directs providers to “[c]ode only a confirmed diagnosis of [COVID-19] as documented by the provider, documentation of a positive COVID-19 test result, or a presumptive positive COVID-19 test result.” The coding guidance further specifies that “[i]n this context, ‘confirmation’ does not require documentation of the type of test performed; the provider’s documentation that the individual has COVID-19 is sufficient.” Based on the August 17, 2020 MLN Matters article now requiring the medical record to include positive viral test results, we may see further updates to CDC guidance in the coming months.
In the August 17, 2020 MLN Matters article, CMS also states that the IPPS Pricer will continue to apply the 20% increase to the DRG weighting factor for diagnosis code U07.1 but may conduct post-payment review to confirm the presence of a positive COVID-19 laboratory test in the medical record. If the required test is not documented in the medical record for admissions on or after September 1, 2020, the additional payment resulting from the 20 percent increase in the MS-DRG weight will be recouped. If a hospital diagnoses a patient with COVID-19 consistent with CDC coding guidelines but does not have evidence of a positive test result, the hospital can decline the additional payment at the time of claims submission to avoid the repayment.
While access to the tests required under the MLN Matters article may be less difficult to obtain now, these changes have the potential to limit payments to hospitals combatting the pandemic. As noted above, the new requirements are also more stringent than the CDC coding guidance, which does not require documentation of the particular type of test performed and specifies that the provider’s documentation that the patient has COVID-19 is sufficient.
To view a copy of CMS’s August 17, 2020 MLN Matters article, please click here.
