Starting next week, CMS is requiring hospitals have positive COVID-19 laboratory tests in patients' records to qualify for Medicare's 20% add-on payment.
The new rule, which CMS said seeks to address "potential Medicare program integrity risks," applies to admissions beginning Sept. 1. Until now, CMS guidance has said a provider's documentation—but not a positive test result—is sufficient to receive the 20% higher Medicare reimbursement for inpatient COVID treatment.
CMS will continue to automatically apply the 20% add-on payment for COVID-19 claims after the rule takes effect. The agency will enforce the requirement through post-payment audits, with the extra 20% being recouped if no positive test results are found.
Opinions vary on how much burden the new rule will place on providers, especially now that COVID-19 tests have become more widely available. Northwell Health, a 23-hospital system in New York that treated tens of thousands of COVID patients when the region was inundated early in the pandemic, already tests every patient who enters its hospitals, plus repeat tests if they initially test negative, said Dr. Mark Jarrett, Northwell's chief quality officer.
"Quite frankly, I can understand why they want to ensure that people aren't labeling people with COVID when they're really not," he said.
The American Hospital Association, by contrast, is asking CMS to walk back the new requirement. The lobbying group argued in a letter sent to CMS Administrator Seema Verma on Wednesday that requiring test results would put a "substantial administrative burden" on hospitals and provider documentation should continue to suffice.
"Basing the COVID-19 diagnosis code on clinical judgment alone — in line with coding rules — continues to be an important approach given that test accuracy may not be reliable, re-testing is unnecessarily onerous, and some communities face persistent testing shortages," wrote Ashley Thompson, the AHA's senior vice president of public policy analysis and development.
CMS did not respond to a request for comment.
The accuracy of some tests has been largely unknown, especially after the FDA early on approved many quickly devised tests based on limited science. Even as COVID cases continue to surge, testing backlogs and extended turnaround times are not uncommon.
In addition to a provider's confirmation, hospitals have until now been able to use state or local COVID-19 test results even if they weren't confirmed by the CDC to get the 20% add-on payment. That will no longer fly. The CMS now requires viral testing—meaning molecular or antigen—consistent with CDC guidelines.
The two International Classification of Diseases, Tenth revision—ICD-10—codes used to identify COVID patients are U07.1 for discharges on or after April 1 and, before that, B97.29 for discharges on or after Jan. 27.
The AHA warned that in some cases, hospitals might have to dedicate considerable time and effort trying to get test results from third-party providers and manually enter them into their medical records. In some cases, hospitals will ultimately have to retest the patients if they can't obtain the results.
"This is not only unduly burdensome and potentially wasteful, but it also may lead to longer hospital stays, higher costs and additional discomfort for patients who are already suffering," AHA's Thompson wrote.
Amanda Hayes-Kibreab, a healthcare partner with King & Spalding, said her hospital clients say COVID-19 tests are now much easier to access, and many are testing all patients suspected of having coronavirus, which makes the new CMS rule more workable.
"Because testing is so much more available than it was, it may not have as significant an impact in practice," she said.
