Section 3710 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act established an increase in the weighting factor of the assigned diagnosis-related group by 20 percent for an individual diagnosed with COVID-19 discharged during the COVID-19 public health emergency period.
Effective with admissions occurring on or after September 1, 2020, claims eligible for the 20 percent increase in the Medicare Severity-Diagnosis Related Group (MS-DRG) weighting factor 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, for example, molecular or antigen, consistent with CDC guidelines.
The test may be performed either during the hospital admission or prior to the hospital admission.
A viral test performed within 14 days of the hospital admission, including a test performed by an entity other than the hospital, notated in the patient’s medical record to satisfy the documentation requirement.
The Pricer will apply the 20 percent increase when determining IPPS payments for discharges that report the ICD-10-CM diagnosis code U07.1 (COVID-19).
A post-payment medical review may be conducted 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.
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 payment resulting from the application of the 20 percent increase in the MS-DRG relative weight at the time of claim payment to avoid the repayment. To do this, you must inform us and we will notate the claim with the appropriate coding for processing.
For proper claim processing when there is no evidence of a positive COVID-19 laboratory test documented in the patient’s medical record, bill the claim as follows:
Electronic claim 837I
Report "No Pos Test" under Billing Note NTE02.
Paper claim (UB-04)
Notate "No Pos Test" in remarks.
Fiscal Intermediary Shared System (FISS)
Report “No Pos Test” in position one in the remarks field.
Note: To ensure proper payment, report exactly as listed. Capitalization is not an issue. To avoid processing issues, do not add quotes around the wording, commas, periods, the full word "positive", or any other words to or before this statement.
If additional remarks are need, add them to the second line of the remarks field to avoid interference.
You may adjust your claims with a date of service of September 1, 2020 or after that was submitted prior to the Pricer update occurring October 5, 2020, by adding these remarks after October 5, 2020 and resubmitting the claim for processing.
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