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Positive COVID-19 Test Required for Hospitals to Get Boosted Inpatient Medicare Payment

Positive COVID-19 Test Required for Hospitals to Get Boosted Inpatient Medicare Payment

Based on a provision in the Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted on March 27, 2020, hospitals are receiving a 20 percent increase in payment for individuals being treated for COVID-19. Starting September 1, CMS is imposing a new requirement in order for hospitals to receive the additional funds.

From the time the temporary change was enacted, the increased payment rate has been applied via a reweighting of the assigned Diagnosis-Related Group (DRG) for individuals who were discharged with ICD-10-CM diagnosis codes 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 or U07.1 (COVID-19) for discharges occurring on or after April 1, 2020.

Beginning with admissions on or after September 1, 2020, patients diagnosed with COVID-19 will also need to have the results of a positive COVID-19 test within 14 days prior to their admission in their medical record in order for the DRG reweighting to apply. According to the Centers for Medicare and Medicaid Services (CMS), the test may be performed either during the hospital admission or prior and can even be performed by an entity other than the hospital, such as a local health department. Results manually entered into the patient’s medical record will satisfy the documentation requirement. 

If a patient had a positive COVID-19 test more than 14 days prior to admission, CMS has said they will consider “whether there are complex medical factors in addition to that test result for purposes of this documentation requirement.”

CMS also has indicated that they may conduct post-payment medical reviews to confirm the presence of a positive COVID-19 laboratory test. If no test is present in the medical record and the provider did receive the 20 percent increase, the extra payment amount will be recouped. 

It’s also possible for a hospital to diagnose a patient with COVID-19 without a positive COVID-19 test and decline the additional payment to avoid the recoupment. To do so, the hospital would simply inform its Medicare Administrative Contractor, who will notate the claim and avoid applying the 20 percent increase.

For more information about this and other COVID-19 Policies for Hospitals, Long-Term Care Hospitals, and Inpatient Rehabilitation Facilities due to Provisions of the CARES Act, review the following documents:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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