CMS Now Mandating Positive Lab Tests to Qualify for 20-Percent Increase in COVID Cost Weighting

The move is already stirring up questions and concerns.

Amid the more than 300 pages of the Coronavirus Aid, Relief, and Economic Security (CARES) Act signed into law back in March was a clause of great interest to healthcare providers: a provision to increase the weighting factor of the applicable Diagnosis-Related Group (DRG) listing by 20 percent for any patient diagnosed with COVID-19 and discharged during the continuing federally declared public health emergency (PHE).

Suddenly, however, that provision now comes with strings attached.

An MLN Matters article issued Monday noted that claims eligible for the 20-percent increase will also be required to include a positive COVID-19 lab test result, documented in the patient record, for all admissions occurring on or after Sept. 1. The reasoning given for the change was to “address potential Medicare program integrity risks.”

“The test need not be performed during the index admission, but it is mandated to have been performed within 14 days of the hospitalization. The notice states it can be ‘manually entered’ into the patient’s medical record,” noted Dr. Erica Remer, ICD10monitor Editorial Board member and co-host of the Talk-Ten-Tuesdays weekly Internet radio broadcast. “In other words, a positive test which predates the admission can be imported into medical record and serve as proof without requiring re-testing. This may be especially problematic if a patient has a positive test in a different institution or healthcare system than the one in which they are hospitalized, or they self-identified and had it done at CVS.”

Remer noted that the World Health Organization (WHO), moving at unprecedented speed, incorporated a new ICD-10 code of U07.1, indicating a COVID-19 diagnosis, on April 1 – less than a month before the pandemic started ravaging parts of the U.S. But the U.S. healthcare system did not import U07.2, COVID-19, virus not identified, she added.

“It is extremely important that the clinician be able to make the diagnosis of COVID-19 clinically,” Remer said. “Not only have we had significant issues in having sufficient testing to be able to perform it on any patient we feel warrants it, but there are many false negatives, up to 30 percent. A physician must treat a patient appropriately even in the face of a negative test result.”

All of which adds up to the new policy carrying the potential to create plenty of confusion.

“What about the patient who has a quintessential presentation of COVID-19 and a negative test? How many times must it be repeated before giving up?” Remer asked. “Subjecting a patient to multiple tests, especially if they are nasopharyngeal swab PCR-tests, seems unduly harsh, and a waste of resources.”

What Remer described as “the scariest part” of the new policy is that the Pricer is going to continue to apply the adjustment factor for discharges with U07.1 coded, but the payment will be recouped if the Centers for Medicare & Medicaid Services (CMS) finds during post-payment review that there was no documented laboratory test. If the provider makes the diagnosis on a clinical basis, Remer said, it will be the hospital’s responsibility to decline the additional payment by notifying the Medicare Administrative Contractor (MAC) and having them notate the claim with an internal processing code.

“There is no discussion of this in the MLN Matters article, but what do you think they are going to do, if this is not done in a timely or routine fashion? Interest? Penalties? Prosecution for false claims?” she asked. “Are providers going to stop making the diagnosis on a clinical basis when they can’t obtain a viral test?”

Then there’s one sentence in the notice Remer said she “can’t even interpret:” “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.”

“Actually, I interpret that as ‘good luck with that!’ and “don’t count on that money,’” Remer said.

“Are hospitals not having enough trouble already? They have lost rivers of revenue stream by elective surgeries being put on hold,” Remer added. “Patients who should be seeking medical attention for COVID-unrelated problems aren’t, for fear of being exposed in the hospital. Their first-line healthcare workers are stressed and exposed and infected. They have had to cut salaries, furlough workers, lay off and fire personnel. Haven’t the hospitals and patients suffered enough?!”

For its part, CMS does note in the MLN Matters article that “additional operational guidance will be provided in implementation instructions in the near future.” But with less than two weeks to go before the new policy kicks in, that probably comes as little comfort to providers.

To review the MLN Matters article in its entirety, go online to https://www.cms.gov/files/document/SE20015.pdf.  

The global COVID-19 pandemic has sickened more than 22 million and killed more than 775,000 people worldwide, with the U.S. accounting for approximately a quarter of those figures.