State Rollout Plans Already Underway: How to Prepare for After-Effects of Coding and Reimbursement while Managing Continual Updates for COVID-19

Managing the after-effects of coding and billing as COVID-19 cases start to move through an organization’s billing cycle, while maintaining up-to-date information, could prove challenging.

With ever-changing coding and billing updates, it is difficult not to anticipate a surge of denied claims, or an increase in inaccurately paid claims, related to coding and billing for COVID-19 patients. The creation of new codes, date ranges to which they apply, wavier considerations, modifiers, and condition codes, not to mention the various settings to which these codes may be applied, make ensuring that an organization is up to date a full-time task. It is not unimaginable that payors may experience challenges as well. Accurate documentation and coding are essential. This pandemic is a reminder of the importance of appropriate checks and balances needed to ensure that documentation, coding, and billing are accurate. 

Many organizations are to be commended for their proactive measures implemented during the onset of COVID-19, and many of them have remained quick to implement updates to coding and billing guidelines as new information is released. These dedicated and flexible plans administered will be of great value when claims start moving through the billing process. 

Focusing merely on the typical key considerations for your organization’s success in managing continuous updates may not be enough to solve all of the various coding and billing challenges. Positioning an organization for favorable outcomes requires an array of content experts, with experience in clinical documentation improvement, coding, billing, and claims adjudication. Coupling technology and content experts creates a firm foundation to manage and monitor all aspects of COVID-19, specifically related to patient financial services.

Because of the overabundance of information from the Centers for Medicare & Medicaid Services (CMS) and other sources, it is extremely challenging to remain up-to-date on coding and billing guidelines associated with this virus. Depending on the size of your organization, choose individuals from your clinical documentation improvement (CDI) department to provide (a) physician education related to COVID-19 documentation; (b) nuances of the verbiage used, which represents each code; and (c) the generation of query data regarding the physicians that may need additional education or one-to-one feedback.

Identifying a team of content experts to attack coding and billing of the virus will be key.

All COVID-19 coder teams have experts that can interpret the nuances of COVID-19 coding and documentation. Such an individual is responsible for the accuracy of COVID-19 coding to ensure consistency when capturing COVID-19 information. This person will work directly with CDI in partnering with physicians who require follow-up education. CDI can also be used as a tremendous resource for clinical questions.

COVID-19 billers should understand the rules surrounding claim requirements for billing for COVID-19, many of which have been discussed during recent editions of Talk-Ten-Tuesdays. This person can be a resource for educating departments that are most affected by COVID-19. Technology can trigger a custom edit to recognize COVID-19 cases. A COVID-19 biller or coder can easily work these edits on a prebill edit to ensure claim accuracy before submitting it for billing.

Billing of laboratory services is a complex undertaking. Considering the volume of code selection for COVID-19 laboratory tests, the setting to which they are provided, and all other related idiosyncrasies, it is imperative to have a resource from this area that can also participate in an organization’s education efforts.

Claim adjudication is obviously of paramount importance. With the onset of COVID-19 and the Families First Coronavirus Response Act, there are numerous services for which payors have implemented cost-sharing measures. Technology can assist with this effort. One of several considerations related to cost that organizations do not want to miss is the additional 20 percent for MS-DRGs related to the COVID-19 virus. Some organizations have already programmed their systems to expect this increase, and have created notifications to alert PFS when a claim is not paid at the expected increased rate.

For large organizations with multiple hospitals under various levels of management, it may be helpful to implement a weekly COVID-19 call for collaboration of COVID-19 coding and billing challenges, as well as to promote consistency among hospitals.

It is the responsibility of the healthcare industry to put forth every possible effort in capturing data in a timely and accurate manner. We have witnessed firsthand how the masterful use of data can lead to identifying and overcoming life-altering challenges, and more importantly, protecting the health of the American people.

Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. EST.


Susan Gatehouse, RHIT, CCS,CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Susan Gatehouse is the founder and chief executive officer of Axea Solutions. An industry expert in revenue cycle management, Gatehouse established Axea Solutions in 1998, and currently partners with healthcare organizations across the nation, to craft solutions for unique challenges in the dynamic world of healthcare reimbursement and data management.

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