Positive COVID-19 Test Results Required for 20 Percent Increase to MS-DRG Weighting

Published 01/31/2022

In response to the national emergency that was declared concerning the novel coronavirus (COVID-19) outbreak, a new diagnosis code, U07.1, COVID-19, has been implemented, effective April 1, 2020. Providers should use this new code, U07.1, where appropriate, for discharges on or after April 1, 2020.  

To address potential Medicare program integrity risks, inpatient COVID-19 claims will require a positive viral test result to be eligible for the 20 percent increase in the MS-DRG weighting factor, effective for admissions on or after September 1, 2020. The test must be performed within 14 days of admission, and the results must be documented in the patient’s medical record.

According to MLN Matters SE20015, only molecular or antigen laboratory testing, consistent with the CDC’s guidelines, may be used. Tests may be performed during or prior to the hospital admission. Tests may be performed by entities other than the admitting hospital — for example, by a local government-run testing center — and manually entered into the patients’ medical records.

CMS MLN Matters SE20015 (PDF) states the following.  

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 prior to the hospital admission. For this purpose, a viral test performed within 14 days of the hospital admission, including 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. For example, a copy of a positive COVID-19 test result that was obtained a week before the admission from a local government run testing center can be added to the patient’s medical record. In the rare circumstance where a viral 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.

To avoid the risk of an audit and recoupment, a hospital that diagnoses a patient with COVID-19 consistent with coding guidelines but without a positive test result in the patient’s medical record, as defined in MLN SE20015, can decline, at the time of claim submission, the additional 20 percent increase in MS-DRG relative weight. To decline the additional payment of the 20 percent increase in the MS-DRG relative weight, the hospital must inform Palmetto GBA by noting the claim.

To notify MACs that there is no evidence of a positive COVID-19 laboratory test documented in the patient’s medical record, providers must enter a Billing Note NTE02 “No Pos Test” on the electronic claim 837I or a remark “No Pos Test” on a paper claim.

In response to the administration of IV Remdesivir in an outpatient setting (e.g. outpatient hospital department or physicians’ office) is an off-label use of the drug. In such circumstances, Palmetto GBA will provide discretionary coverage for an outpatient therapeutic infusion of Remdesivir. This decision is based on authoritative medical literature such as the NIH Covid-19 Treatment Guidelines Panel and on accepted standards of medical practice.  Coverage of outpatient therapeutically infused Remdesivir will be premised on a documented reasonable and necessary standard per the Social Security Act, Title XVIII, 1862 (a) (1) (A). Coverage is also dependent on the outpatient setting’s ability to appropriately manage this infusion.

Key Takeaway

  • Use new code, U07.1, where appropriate, for discharges on or after April 1, 2020
  • Effective for admissions on or after September 1, 2020, only viral testing (i.e. molecular or antigen) laboratory testing, consistent with the CDC guidelines may be used and:
    • Positive COVID-19 viral test result must be documented in the patient’s record and provided if requested
    • Tests may be performed during or 14 days prior to the hospital admission
    • Tests may be performed by entities other than the hospital and manually entered into the patients’ records
  • Avoid risk of audit and recoupment, a hospital without positive test result should decline 20 percent additional payment by informing MAC, by noting the claim
  • IV Remdesivir can be administered in an outpatient setting
  • Documentation has to support that it was reasonable and necessary for the beneficiary to receive the infusion in an outpatient setting

References


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