SunStone is committed to assisting our clients navigate the ever-changing reimbursement and regulatory environment, keeping you a head of the curve and ensuring appropriate reimbursement for services rendered during the COVID-19 public health emergency (“PHE”).
In this special HotStone edition, we are providing the most frequently asked questions from our clients, along with our responses and any associated clarity sought from CMS.
ICD-10-CM CODING GUIDELINES & CLINICAL DOCUMENTATION IMPROVEMENT
1. We understand that the MS-DRG payments are impacted for the COVID-19. How can we obtain the add on payment?
SunStone Response:
Appropriate assignment of COVID-19 diagnosis codes is not only critical to obtaining the newly implemented 20% increase for inpatient claims affected by COVID-19, but also to ensure public health data is appropriately tracked. The ICD-10 MS-DRG Grouper software package has been updated to Version 37.1 R1 to accommodate the new COVID-19 diagnosis code, U07.1 effective for discharges on or after April 1, 2020. Assignment of U07.1, COVID-19, is as follows:
Additionally, outpatient capture of the applicable ICD-10 diagnosis codes are necessary to accurately report the new influx of non-traditional telehealth encounters
2. What are the new COVID-19 diagnosis codes?
SunStone Response:
Given the urgent need to capture the COVID-19 condition in our nation’s claims and surveillance data, The Centers for Disease Control (“CDC”) released an unprecedented off-cycle update. COVID-19 diagnosis coding will fall under one of two separate sets of guidelines based on date of service:
Interim CDC guidance in conjunction with ICD-10-CM Official Guidelines Supplement effective February 20, 2020 for COVID-19 encounters with dates of service prior to April 1, 2020 as follows:
Respiratory illness confirmed as due to COVID-19 are reported as an additional diagnosis B97.29 – Other coronavirus as the cause of diseases classified elsewhere in conjunction with the primary respiratory illness to include pneumonia, acute bronchitis, lower respiratory infection, and acute respiratory distress syndrome (“ARDS”).Additional ICD-10-CM codes are as follows:
- Z03.818 – Encounter for observation of suspected exposure to other biological agents ruled out – is to be reported where there is concern of possible exposure to COVID-19 which is ruled out after evaluation.
- Z20.828 – Contact with and (suspected) exposure to other viral communicable diseases – is to be reported when the patient had an actual exposure to someone confirmed to have COVID-19.
Newly released ICD-10-CM Official Coding and Reporting Guidelines for COVID-19 for dates of service April 1, 2020 through September 30, 2020 can be found at the following link.
https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf
Specifically, U07.1 – COVID-19 is effective for discharges on or after April 1, 2020.
3. Can we append diagnosis code U071.1 for claims after April 1, 2020 when the physician documents that the patient had probable COVID-19?
SunStone Response:
ICD-10-CM code U07.1 is only to be appended when there is explicit documentation to support confirmation of, or presumptive positive test result for COVID-19. A presumptive positive test result means the individual has tested positive for the virus at a local or state level but has not yet been confirmed by the CDC. Asymptomatic individuals who test positive for COVID-19 should also have U07.1 assigned.
Of note, this is an exception to the hospital inpatient guideline Section II, H; for in this context, “confirmation” does not require documentation of the type of test performed. Rather, the provider’s documentation that the patient has COVID-19 is sufficient. However, if the provider documents “suspected”, “possible”, “probable” or “inconclusive” COVID-19, the provider should not assign code U07.1. The CDC and American Hospital Association (“AHA”) recommend providers consider facility-specific coding guidelines to hold inpatient and outpatient claims until the confirmation of COVID-19 has been obtained so as to append the proper diagnosis code.
Similar to the previous guidelines, Z03.818 should be reported for concern of possible exposure to COVID-19 ruled out after evaluation or when the patient has an actual exposure to someone who is confirmed or suspected (not ruled out) to have COVID-19, and the patient either tests negative or the test results are unknown.
Finally, hospitals should report Z11.59 – Encounter for screening for other viral diseases – for asymptomatic patients who are being screened for COVID-19 but have had no known exposure to the virus where the test results are either unknown or negative
LABORATORY SPECIMENS
1. We have set up drive thru tent locations to collect COVID-19 specimens. Is there any payment available for specimen collection?
SunStone Response:
CMS-1744-IFC Section M – Medicare Clinical Laboratory Fee Schedule: Payment for Specimen Collection Purposes of COVID-19 Testing (pages 92-98) states the following:
To identify specimen collection for COVID-19 testing, we are establishing two new level II HCPCS codes. Independent laboratories must use one of these HCPCS codes when billing Medicare for the nominal specimen collection fee for COVID-19 testing during the duration of the PHE for the COVID-19 pandemic.
G2023 – Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source.
G2024 - Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19], from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source.
While the interim final rule explicitly states these codes are intended for independent laboratories, the MLN Connects Special Addition issued Tuesday, March 31, 2020 references use for “clinical diagnostic laboratories”.
We are seeking clarification from CMS regarding how hospitals or medical groups, who have established tent drive-thru testing locations, can capture the additional work associated with performing COVID-19 tests at a remote location and sending to a laboratory for processing. Specifically, we questioned the ability to bill G2023 or CPT 99000- Handling and/or conveyance of specimen for transfer from the office to a laboratory?
BILLING
1. Should condition code DR be used when billing claims that are applicable to the COVID-19 waivers?
SunStone Response:
CMS has clarified that “DR” condition code and “CR” modifier are mandatory for institutional and non-institutional providers in billing situations related to COVID-19 for any claim for which Medicare payment is conditioned on the presence of a “formal waiver” (as defined in the CMS Internet Only Manual, Publication 100-04, Chapter 38, § 10).
According to CMS, the DR condition code is used by institutional providers only, at the claim level, when all of the services/items billed on the claim are related to a COVID-19 waiver. The CR modifier is used by both institutional and non-institutional providers to identify Part B line item services/items that are related to a COVID-19 waiver.
An exception to the CR modifier, is for telehealth services in which CMS has advised that practitioners need only append the 95 modifier.
If you have any reimbursement or regulatory questions concerning COVID-19, please feel free to email Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com.